Provider Demographics
NPI:1528190386
Name:LITE HOUSE INC
Entity Type:Organization
Organization Name:LITE HOUSE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:K.
Authorized Official - Middle Name:CELESTE
Authorized Official - Last Name:KIMBROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-693-9903
Mailing Address - Street 1:120 W PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 27
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-5429
Mailing Address - Country:US
Mailing Address - Phone:910-693-9903
Mailing Address - Fax:
Practice Address - Street 1:26 PINECREST PLZ
Practice Address - Street 2:#126
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-4301
Practice Address - Country:US
Practice Address - Phone:910-693-9903
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418042Medicaid
NC8301495Medicaid