Provider Demographics
NPI:1649359316
Name:THE LIGHTHOUSE - TRAVERSE CITY, LLC
Entity type:Organization
Organization Name:THE LIGHTHOUSE - TRAVERSE CITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-673-2500
Mailing Address - Street 1:PO BOX 289
Mailing Address - Street 2:
Mailing Address - City:CARO
Mailing Address - State:MI
Mailing Address - Zip Code:48723-0289
Mailing Address - Country:US
Mailing Address - Phone:989-673-2500
Mailing Address - Fax:
Practice Address - Street 1:4140 BEACON ST
Practice Address - Street 2:
Practice Address - City:KINGSLEY
Practice Address - State:MI
Practice Address - Zip Code:49649
Practice Address - Country:US
Practice Address - Phone:231-263-1350
Practice Address - Fax:231-263-1353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities