Provider Demographics
NPI:1013733625
Name:THE LIGHT HOUSE LLC
Entity type:Organization
Organization Name:THE LIGHT HOUSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TEMUKA
Authorized Official - Middle Name:HOSKINS
Authorized Official - Last Name:HENDRIX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-324-7223
Mailing Address - Street 1:116 YESTER OAKS WAY E APT J
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27455-3140
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:116 YESTER OAKS WAY E APT J
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27455-3140
Practice Address - Country:US
Practice Address - Phone:336-324-7223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-27
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities