Provider Demographics
NPI:1184264756
Name:LIGHT AND GLORY LLC
Entity type:Organization
Organization Name:LIGHT AND GLORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GERALDINE
Authorized Official - Middle Name:
Authorized Official - Last Name:RICAFORTE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:757-215-6953
Mailing Address - Street 1:1513 MALLORY CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-6419
Mailing Address - Country:US
Mailing Address - Phone:757-215-6953
Mailing Address - Fax:757-467-3604
Practice Address - Street 1:1513 MALLORY CT
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-6419
Practice Address - Country:US
Practice Address - Phone:757-215-6953
Practice Address - Fax:757-467-3604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251J00000XAgenciesNursing Care
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities