Provider Demographics
NPI:1225238421
Name:GUARDIAN LIGHT, INC.
Entity Type:Organization
Organization Name:GUARDIAN LIGHT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBERTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:POWERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-625-5008
Mailing Address - Street 1:PO BOX 1877
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-1877
Mailing Address - Country:US
Mailing Address - Phone:910-642-8609
Mailing Address - Fax:
Practice Address - Street 1:1294 HALLSBORO RD S
Practice Address - Street 2:
Practice Address - City:HALLSBORO
Practice Address - State:NC
Practice Address - Zip Code:28442-9276
Practice Address - Country:US
Practice Address - Phone:910-646-7143
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-024-056320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0961Medicaid