Provider Demographics
NPI:1225166069
Name:LIGHT HOUSE GROUP
Entity Type:Organization
Organization Name:LIGHT HOUSE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-497-0299
Mailing Address - Street 1:408 HARRELL ST
Mailing Address - Street 2:PO BOX 1089
Mailing Address - City:SPRING LAKE
Mailing Address - State:NC
Mailing Address - Zip Code:28390-3607
Mailing Address - Country:US
Mailing Address - Phone:910-497-0299
Mailing Address - Fax:910-497-0297
Practice Address - Street 1:206 WAPITI DR
Practice Address - Street 2:108 ASHTON PL
Practice Address - City:SPRING LAKE
Practice Address - State:NC
Practice Address - Zip Code:28390-1530
Practice Address - Country:US
Practice Address - Phone:910-497-0299
Practice Address - Fax:910-497-0297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL -026-805322D00000X
NCMHL-026-782322D00000X
NCMHL-026-627322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603194Medicaid
NC6603652Medicaid
NC6603907Medicaid