Healthcare Provider Details

I. General information

NPI: 1225166069
Provider Name (Legal Business Name): LIGHT HOUSE GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 WAPITI DR 108 ASHTON PL
SPRING LAKE NC
28390-1530
US

IV. Provider business mailing address

408 HARRELL ST PO BOX 1089
SPRING LAKE NC
28390-3607
US

V. Phone/Fax

Practice location:
  • Phone: 910-497-0299
  • Fax: 910-497-0297
Mailing address:
  • Phone: 910-497-0299
  • Fax: 910-497-0297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberMHL -026-805
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberMHL-026-782
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberMHL-026-627
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier6603194
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 2
Identifier6603652
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 3
Identifier6603907
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: CHARLES DAVENPORT
Title or Position: PRESIDENT
Credential:
Phone: 910-497-0299