Provider Demographics
NPI:1285109587
Name:LIGHTHOUSE HEALTH PLAN, LLC
Entity type:Organization
Organization Name:LIGHTHOUSE HEALTH PLAN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:METHENY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-908-3001
Mailing Address - Street 1:700 E GREGORY ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32502-4142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 E GREGORY ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32502-4142
Practice Address - Country:US
Practice Address - Phone:850-908-3001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-12
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1001225-02Medicaid
FL1001225-01Medicaid