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General NPI Number Information
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NPI Number | 1386956183
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Entity Type | Organization
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Legal Business Name | LORD IS THE LIGHT
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Dates
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Enumeration Date | 07/08/2010
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Last Update Date | 07/08/2010
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Provider Practice Location Address
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Address Line | 2802 ELDERMONT ST APT E
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City | BURLINGTON
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State | NC
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Zip | 27215-6111
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Country | US
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Telephone | 336-270-6217
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Fax |
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Provider Business Mailing Address
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Address Line | 2802 ELDERMONT ST APT E
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City | BURLINGTON
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State | NC
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Zip | 27215-6111
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Country | US
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Telephone | 336-270-6217
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. KIMBERLY MICHELLE FOUST
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Credential |
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Telephone | 336-213-5830
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | MHL-001-196
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License Number State | NC
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