Provider Demographics
NPI:1467599316
Name:GUIDING LIGHT YOUTH AND FAMILY SERVICES
Entity Type:Organization
Organization Name:GUIDING LIGHT YOUTH AND FAMILY SERVICES
Other - Org Name:POLKTON ROAD
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:TOWLER
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:704-684-0257
Mailing Address - Street 1:7931 ANSONVILLE POLKTON RD
Mailing Address - Street 2:
Mailing Address - City:POLKTON
Mailing Address - State:NC
Mailing Address - Zip Code:28135-9336
Mailing Address - Country:US
Mailing Address - Phone:704-684-0257
Mailing Address - Fax:704-684-0258
Practice Address - Street 1:1233 MORNINGSIDE MEADOW LN
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28104-8553
Practice Address - Country:US
Practice Address - Phone:704-684-0257
Practice Address - Fax:704-684-0258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300505GMedicaid
NC8300505Medicaid
NC8300505BMedicaid