Provider Demographics
NPI:1740745694
Name:LIGHTHOUSE BEHAVIORAL HEALTH CENTER LLC
Entity Type:Organization
Organization Name:LIGHTHOUSE BEHAVIORAL HEALTH CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VERNON
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-651-1857
Mailing Address - Street 1:1119 E MONUMENT ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-4119
Mailing Address - Country:US
Mailing Address - Phone:443-708-5056
Mailing Address - Fax:
Practice Address - Street 1:1119 E MONUMENT ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-4119
Practice Address - Country:US
Practice Address - Phone:443-708-5056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center