Provider Demographics
NPI:1306315056
Name:LIGHTHOUSE WELLNESS INSTITUTE INC
Entity type:Organization
Organization Name:LIGHTHOUSE WELLNESS INSTITUTE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:BARTELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-205-9000
Mailing Address - Street 1:2590 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-1741
Mailing Address - Country:US
Mailing Address - Phone:630-205-9000
Mailing Address - Fax:
Practice Address - Street 1:2182 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:NORTH BEND
Practice Address - State:OR
Practice Address - Zip Code:97459
Practice Address - Country:US
Practice Address - Phone:541-808-9697
Practice Address - Fax:541-808-9699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-23
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500748374Medicaid