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General NPI Number Information
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NPI Number | 1407483316
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Entity Type | Organization
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Legal Business Name | LIGHTHOUSE RESIDENTIAL HOME
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Dates
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Enumeration Date | 03/23/2020
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Last Update Date | 04/09/2020
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Provider Practice Location Address
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Address Line | 5219 SUMMERLEAF DR
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23234-2817
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Country | US
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Telephone | 804-337-1403
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Fax | 804-590-2763
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Provider Business Mailing Address
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Address Line | 13518 MARSH ELDER CT
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City | CHESTERFIELD
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State | VA
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Zip | 23838-3406
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Country | US
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Telephone | 804-337-1403
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Fax | 804-590-2763
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Authorized Official
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Title or Position | PRESIDENT
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Name | ROBERT EARL OWENS JR.
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Credential |
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Telephone | 804-337-1403
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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 |
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License Number State |
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