Provider Demographics
NPI:1629494380
Name:LIGHTHOUSE FAMILY CARE
Entity Type:Organization
Organization Name:LIGHTHOUSE FAMILY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:BYRDSONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-901-9777
Mailing Address - Street 1:9612 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-2309
Mailing Address - Country:US
Mailing Address - Phone:804-901-9777
Mailing Address - Fax:
Practice Address - Street 1:9612 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-2309
Practice Address - Country:US
Practice Address - Phone:804-901-9777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-05
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health