Provider Demographics
NPI:1407201569
Name:LIGHTHOUSE NATURAL MEDICINE, PLLC
Entity type:Organization
Organization Name:LIGHTHOUSE NATURAL MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KNUTSON
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:425-789-1779
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-943-4180
Mailing Address - Fax:888-431-8819
Practice Address - Street 1:117 PARK AVE
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-1619
Practice Address - Country:US
Practice Address - Phone:425-789-1779
Practice Address - Fax:888-431-8819
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIGHTHOUSE NATURAL MEDICINE, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT00001592332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site