Provider Demographics
NPI:1417298951
Name:THE LIGHTHOUSE DIALYSIS FOUNDATION, INC.
Entity Type:Organization
Organization Name:THE LIGHTHOUSE DIALYSIS FOUNDATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRWOMAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:K
Authorized Official - Last Name:TERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-659-7444
Mailing Address - Street 1:301 S CHURCH ST
Mailing Address - Street 2:SUITE #260
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-5755
Mailing Address - Country:US
Mailing Address - Phone:252-316-1033
Mailing Address - Fax:252-822-0097
Practice Address - Street 1:2901 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TARBORO
Practice Address - State:NC
Practice Address - Zip Code:27886-1920
Practice Address - Country:US
Practice Address - Phone:252-316-1033
Practice Address - Fax:252-822-0097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-07
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization