Provider Demographics
NPI:1114400272
Name:LAMP ON A STAND LIFE CENTER LLC
Entity Type:Organization
Organization Name:LAMP ON A STAND LIFE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BURCHETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-423-6140
Mailing Address - Street 1:210 NE 39TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK ISLAND
Mailing Address - State:NC
Mailing Address - Zip Code:28465-5639
Mailing Address - Country:US
Mailing Address - Phone:336-423-6140
Mailing Address - Fax:
Practice Address - Street 1:130 HILL ST
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-2416
Practice Address - Country:US
Practice Address - Phone:336-423-6140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)