Provider Demographics
NPI:1407218084
Name:LIGHTHOUSE TREATMENT CENTER
Entity Type:Organization
Organization Name:LIGHTHOUSE TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:THAER
Authorized Official - Middle Name:
Authorized Official - Last Name:JOUDEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-288-2006
Mailing Address - Street 1:3919 S HIGHWAY 14
Mailing Address - Street 2:BLDG A
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-6138
Mailing Address - Country:US
Mailing Address - Phone:864-288-2006
Mailing Address - Fax:864-288-1678
Practice Address - Street 1:3919 S HIGHWAY 14
Practice Address - Street 2:BLDG A
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6138
Practice Address - Country:US
Practice Address - Phone:864-288-2006
Practice Address - Fax:864-288-1678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-23
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility