Basic Information
| Provider Information | |||||||||
| NPI: | 1477067072 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAMPLIGHT FM PLC LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAMPLIGHT OF FORT MYERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3630 ILLINOIS RD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468042062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2607979482 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1896 PARK MEADOWS DR | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339073738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399395421 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2017 | ||||||||
| LastUpdateDate: | 11/20/2017 | ||||||||
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| AuthorizedOfficialLastName: | PETRAS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | CO-OWNER/COO | ||||||||
| AuthorizedOfficialTelephone: | 2607979482 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.