Provider Demographics
NPI:1548085079
Name:LIGHTHOUSE PREMIUM HOME CARE LLC
Entity type:Organization
Organization Name:LIGHTHOUSE PREMIUM HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OSWALD
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-886-4585
Mailing Address - Street 1:3300 COUNTY ROAD 10
Mailing Address - Street 2:STE 200D
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429
Mailing Address - Country:US
Mailing Address - Phone:612-886-4585
Mailing Address - Fax:
Practice Address - Street 1:3300 COUNTY ROAD 10
Practice Address - Street 2:STE 200D
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429
Practice Address - Country:US
Practice Address - Phone:612-886-4585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No251E00000XAgenciesHome Health