Provider Demographics
NPI:1972618197
Name:LIGHTHOUSE FAMILY CARE
Entity type:Organization
Organization Name:LIGHTHOUSE FAMILY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ILEANA
Authorized Official - Middle Name:BRACETE
Authorized Official - Last Name:SOSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-466-0600
Mailing Address - Street 1:9400 GLADIOLUS DR
Mailing Address - Street 2:STE 50
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908
Mailing Address - Country:US
Mailing Address - Phone:239-437-7070
Mailing Address - Fax:239-437-9022
Practice Address - Street 1:9400 GLADIOLUS DR
Practice Address - Street 2:STE 50
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908
Practice Address - Country:US
Practice Address - Phone:239-437-7070
Practice Address - Fax:239-437-9022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59779207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F01271Medicare UPIN
12924XMedicare ID - Type Unspecified