Provider Demographics
NPI:1780853051
Name:LIGHTHOUSE RTC
Entity Type:Organization
Organization Name:LIGHTHOUSE RTC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:HUNINGER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:928-257-2293
Mailing Address - Street 1:964 W 34TH PL
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85365-4357
Mailing Address - Country:US
Mailing Address - Phone:928-257-2293
Mailing Address - Fax:
Practice Address - Street 1:13708 E 50TH ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85367-8503
Practice Address - Country:US
Practice Address - Phone:928-246-4664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3048322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children