Provider Demographics
NPI:1649436015
Name:LIGHTHOUSE CARE CENTER OF OCONEE
Entity type:Organization
Organization Name:LIGHTHOUSE CARE CENTER OF OCONEE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DEBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:THEIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-651-0005
Mailing Address - Street 1:3100 PERIMETER PKWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-4583
Mailing Address - Country:US
Mailing Address - Phone:706-651-0005
Mailing Address - Fax:706-651-7666
Practice Address - Street 1:391 WHITE ROCK RD
Practice Address - Street 2:
Practice Address - City:TAMASSEE
Practice Address - State:SC
Practice Address - Zip Code:29686-2015
Practice Address - Country:US
Practice Address - Phone:864-944-9875
Practice Address - Fax:706-651-7666
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIGHTHOUSE CARE CENTER OF AUGUSTA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-05
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23245800006261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN885MXHMedicaid