=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407218084
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIGHTHOUSE TREATMENT CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2016
-----------------------------------------------------
Last Update Date | 03/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3919 S HIGHWAY 14 BLDG A
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29615-6138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-288-2006
-----------------------------------------------------
Fax | 864-288-1678
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3919 S HIGHWAY 14 BLDG A
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29615-6138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-288-2006
-----------------------------------------------------
Fax | 864-288-1678
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | THAER JOUDEH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 864-288-2006
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------