Provider Demographics
NPI:1043929664
Name:LIGHT RESIDENTIAL SERVICE LLC
Entity type:Organization
Organization Name:LIGHT RESIDENTIAL SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MULUSEW
Authorized Official - Middle Name:GETIE
Authorized Official - Last Name:KEBTIE
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN, MSC
Authorized Official - Phone:301-633-9649
Mailing Address - Street 1:16730 BUCKINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027-1044
Mailing Address - Country:US
Mailing Address - Phone:301-633-9649
Mailing Address - Fax:503-344-6669
Practice Address - Street 1:16730 BUCKINGHAM DR
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:OR
Practice Address - Zip Code:97027-1044
Practice Address - Country:US
Practice Address - Phone:301-633-9649
Practice Address - Fax:503-344-6669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-22
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty