MEDICARE: LIGHT AND GLORY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	251J00000X	Nursing Care Agency
2	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
3	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1184264756
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIGHT AND GLORY LLC

Provider Business Mailing Address
First Line	:	1513 MALLORY CT
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-6419
Country	:	US
Telephone Number	:	757-215-6953
Fax Number	:	757-467-3604

Provider Business Practice Location Address
First Line	:	1513 MALLORY CT
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-6419
Country	:	US
Telephone Number	:	757-215-6953
Fax Number	:	757-467-3604

Authorized Official
Title or Position	:	PROGRAM DIRECTOR
Name	:	GERALDINE RICAFORTE
Credential	:	RN
Telephone Number	:	757-215-6953

Provider Enumeration Date	:	01/13/2020
Last Update Date	:	01/13/2020

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Directions to “LIGHT AND GLORY LLC ” Practice Location

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