MEDICARE: LIGHTHOUSE RESIDENTIAL HOME

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1407483316
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIGHTHOUSE RESIDENTIAL HOME

Provider Business Mailing Address
First Line	:	13518 MARSH ELDER CT
Second Line	:
City	:	CHESTERFIELD
State	:	VA
Zip	:	23838-3406
Country	:	US
Telephone Number	:	804-337-1403
Fax Number	:	804-590-2763

Provider Business Practice Location Address
First Line	:	5219 SUMMERLEAF DR
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23234-2817
Country	:	US
Telephone Number	:	804-337-1403
Fax Number	:	804-590-2763

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ROBERT EARL OWENS JR.
Credential	:
Telephone Number	:	804-337-1403

Provider Enumeration Date	:	03/23/2020
Last Update Date	:	04/09/2020

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Directions to “LIGHTHOUSE RESIDENTIAL HOME ” Practice Location

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