Basic Information
| Provider Information | |||||||||
| NPI: | 1104926351 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIGHTHOUSE HOSPICE OF ALABAMA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 965 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360810965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3345664357 | ||||||||
| FaxNumber: | 3345662220 | ||||||||
| Practice Location | |||||||||
| Address1: | 413 S BRUNDIDGE ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | TROY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360813331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3345664357 | ||||||||
| FaxNumber: | 3345662220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | OUTLAW | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3345664357 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 11735 | AL | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | PIC1636E | 05 | AL | MEDICAID | 013221 | 01 | AL | BCBS OF AL PROVIDER # | OTHER |