Provider Demographics
NPI:1013392679
Name:LIGHT HOUSE GROUP HOME
Entity Type:Organization
Organization Name:LIGHT HOUSE GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIGG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-859-0259
Mailing Address - Street 1:20 JERVEY RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TRYON
Mailing Address - State:NC
Mailing Address - Zip Code:28782-0017
Mailing Address - Country:US
Mailing Address - Phone:828-859-0259
Mailing Address - Fax:
Practice Address - Street 1:85 MIMOSA INN LN
Practice Address - Street 2:
Practice Address - City:TRYON
Practice Address - State:NC
Practice Address - Zip Code:28782-8685
Practice Address - Country:US
Practice Address - Phone:828-859-0259
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SYNERGY IN ACTION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-24
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X
NCMHL075025320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities