# LIGHT HOUSE GROUP

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1225166069
- **Authorized official:** CHARLES DAVENPORT (PRESIDENT)
- **Authorized official phone:** (910) 497-0299

## Contact information

- **Practice address:** 206 WAPITI DR, 108 ASHTON PL, SPRING LAKE, NC 28390-1530
- **Practice address phone:** (910) 497-0299
- **Practice address fax:** (910) 497-0297
- **Mailing address:** 408 HARRELL ST, PO BOX 1089, SPRING LAKE, NC 28390-3607
- **Mailing address phone:** (910) 497-0299
- **Mailing address fax:** (910) 497-0297

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 322D00000X | Emotionally Disturbed Childrens' Residential Treatment Facility | MHL -026-805 | NC | — |
| 322D00000X | Emotionally Disturbed Childrens' Residential Treatment Facility | MHL-026-627 | NC | Yes |
| 322D00000X | Emotionally Disturbed Childrens' Residential Treatment Facility | MHL-026-782 | NC | — |

## Other

- **Enumeration date:** 03/02/2007
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 6603194 | — | NC |
| 05 | — | 6603652 | — | NC |
| 05 | — | 6603907 | — | NC |