Provider Demographics
NPI:1811255375
Name:BEACON LIGHT ALTERNATIVE SERVICES
Entity type:Organization
Organization Name:BEACON LIGHT ALTERNATIVE SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:KEON
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:860-597-1575
Mailing Address - Street 1:70 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-3204
Mailing Address - Country:US
Mailing Address - Phone:860-597-1575
Mailing Address - Fax:
Practice Address - Street 1:70 FOREST ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-3204
Practice Address - Country:US
Practice Address - Phone:860-597-1575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251B00000XAgenciesCase Management