Healthcare Provider Details

I. General information

NPI: 1437635141
Provider Name (Legal Business Name): LIGHTHOUSE COMMUNITY INVESTMENT AGENCY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2018
Last Update Date: 07/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 PRICHARD STREET
WILLIAMSON WV
25661
US

IV. Provider business mailing address

102 PRICHARD STREET
WILLIAMSON WV
25661
US

V. Phone/Fax

Practice location:
  • Phone: 304-475-4663
  • Fax: 304-475-1450
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JUSTIN SCOTT ROSS
Title or Position: HR
Credential:
Phone: 304-475-4663