Healthcare Provider Details

I. General information

NPI: 1649359316
Provider Name (Legal Business Name): THE LIGHTHOUSE - TRAVERSE CITY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 01/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4140 BEACON ST
KINGSLEY MI
49649
US

IV. Provider business mailing address

PO BOX 289
CARO MI
48723-0289
US

V. Phone/Fax

Practice location:
  • Phone: 231-263-1350
  • Fax: 231-263-1353
Mailing address:
  • Phone: 989-673-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MARK WILSON
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 989-673-2500