Healthcare Provider Details

I. General information

NPI: 1205754603
Provider Name (Legal Business Name): LIGHTHOUSE RESIDENTIAL CARE FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4033 DELREE ST LOT 31
WEST COLUMBIA SC
29170-1534
US

IV. Provider business mailing address

4033 DELREE ST LOT 31
WEST COLUMBIA SC
29170-1534
US

V. Phone/Fax

Practice location:
  • Phone: 803-957-0583
  • Fax:
Mailing address:
  • Phone: 803-957-0583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: ANGELINE SMITH
Title or Position: DIRECTOR
Credential:
Phone: 803-957-0583