MEDICARE: LIGHT HOUSE GROUP

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	MHL -026-805	NC
2	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	MHL-026-782	NC
3	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	MHL-026-627	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225166069
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIGHT HOUSE GROUP

Provider Business Mailing Address
First Line	:	408 HARRELL ST
Second Line	:	PO BOX 1089
City	:	SPRING LAKE
State	:	NC
Zip	:	28390-3607
Country	:	US
Telephone Number	:	910-497-0299
Fax Number	:	910-497-0297

Provider Business Practice Location Address
First Line	:	206 WAPITI DR
Second Line	:	108 ASHTON PL
City	:	SPRING LAKE
State	:	NC
Zip	:	28390-1530
Country	:	US
Telephone Number	:	910-497-0299
Fax Number	:	910-497-0297

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CHARLES DAVENPORT
Credential	:
Telephone Number	:	910-497-0299

Provider Enumeration Date	:	03/02/2007
Last Update Date	:	08/22/2020

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Directions to “LIGHT HOUSE GROUP ” Practice Location

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