=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386883833
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIGHT HOUSE MEMORY CARE AGENCY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2009
-----------------------------------------------------
Last Update Date | 07/01/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 926 COMMERCE ST
-----------------------------------------------------
City | LYNCHBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24504-1602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-845-1777
-----------------------------------------------------
Fax | 434-845-1788
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 926 COMMERCE ST
-----------------------------------------------------
City | LYNCHBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24504-1602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-845-1777
-----------------------------------------------------
Fax | 434-845-1788
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. WAYNE ELLIOTT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 434-845-3318
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | HCO09548
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | HCO09548
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------