Healthcare Provider Details

I. General information

NPI: 1174899454
Provider Name (Legal Business Name): LIGHT HORSE HEALTHCARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2012
Last Update Date: 11/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 DAN PROCTOR DRIVE SUITE 3300
ST MARYS GA
31558
US

IV. Provider business mailing address

PO BOX 5250
ST MARYS GA
31558
US

V. Phone/Fax

Practice location:
  • Phone: 912-882-3800
  • Fax: 912-882-3303
Mailing address:
  • Phone: 912-882-3800
  • Fax: 912-882-3303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. CARLENE H TAYLOR
Title or Position: EXE DIRECTOR
Credential: LPC
Phone: 912-882-3800