Provider Demographics
NPI:1710483714
Name:LIGHTHOUSE RESIDENITAL
Entity Type:Organization
Organization Name:LIGHTHOUSE RESIDENITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:HORNBUCKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-465-0920
Mailing Address - Street 1:10200 W 44TH AVE STE 400B
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-6826
Mailing Address - Country:US
Mailing Address - Phone:720-465-0920
Mailing Address - Fax:303-337-0038
Practice Address - Street 1:10200 W 44TH AVE STE 400B
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6826
Practice Address - Country:US
Practice Address - Phone:720-465-0920
Practice Address - Fax:303-337-0038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-30
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities