Provider Demographics
NPI:1407483316
Name:LIGHTHOUSE RESIDENTIAL HOME
Entity Type:Organization
Organization Name:LIGHTHOUSE RESIDENTIAL HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:804-337-1403
Mailing Address - Street 1:13518 MARSH ELDER CT
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23838-3406
Mailing Address - Country:US
Mailing Address - Phone:804-337-1403
Mailing Address - Fax:804-590-2763
Practice Address - Street 1:5219 SUMMERLEAF DR
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23234-2817
Practice Address - Country:US
Practice Address - Phone:804-337-1403
Practice Address - Fax:804-590-2763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-23
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities