Provider Demographics
NPI:1740011063
Name:ANCHOR OF LIGHT LLC
Entity type:Organization
Organization Name:ANCHOR OF LIGHT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCRAE
Authorized Official - Suffix:
Authorized Official - Credentials:LVN
Authorized Official - Phone:773-412-2926
Mailing Address - Street 1:2310 N HENDERSON AVE APT 1559
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-7891
Mailing Address - Country:US
Mailing Address - Phone:469-337-7687
Mailing Address - Fax:
Practice Address - Street 1:4066 PASSAGE WAY
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:TX
Practice Address - Zip Code:75146-0106
Practice Address - Country:US
Practice Address - Phone:469-337-7687
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities