Provider Demographics
NPI:1871772251
Name:LIGHTHOUSE OF LA INC.
Entity type:Organization
Organization Name:LIGHTHOUSE OF LA INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JUDE
Authorized Official - Middle Name:
Authorized Official - Last Name:NJOKU
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:310-908-3641
Mailing Address - Street 1:2930 W IMPERIAL HIGHWAY
Mailing Address - Street 2:SUITE 200M
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90303-3142
Mailing Address - Country:US
Mailing Address - Phone:310-630-5820
Mailing Address - Fax:
Practice Address - Street 1:2930 W IMPERIAL HWY
Practice Address - Street 2:SUITE 200M
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90303-3143
Practice Address - Country:US
Practice Address - Phone:310-630-5820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANONE YET302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization