Provider Demographics
NPI:1568280592
Name:LIGHTHOUSE COMMUNITY SUPPORT
Entity type:Organization
Organization Name:LIGHTHOUSE COMMUNITY SUPPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANGER
Authorized Official - Prefix:
Authorized Official - First Name:DAESHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:PITTS
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:302-883-7787
Mailing Address - Street 1:600 W DIVISION ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-2702
Mailing Address - Country:US
Mailing Address - Phone:267-815-4350
Mailing Address - Fax:
Practice Address - Street 1:600 W DIVISION ST UNIT B
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-2702
Practice Address - Country:US
Practice Address - Phone:267-815-4350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1831481761Medicaid