Organization
LIGHT HOUSE GROUP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CHARLES DAVENPORT (PRESIDENT)
(910) 497-0299
Entity
Organization
Contact information
Practice address
206 WAPITI DR, 108 ASHTON PL, SPRING LAKE, NC 28390-1530
(910) 497-0299
(910) 497-0297
Mailing address
408 HARRELL ST, PO BOX 1089, SPRING LAKE, NC 28390-3607
(910) 497-0299
(910) 497-0297
Taxonomy
Speciality
Code
Description
License number
State
322D00000X
Emotionally Disturbed Childrens' Residential Treatment Facility
MHL -026-805
NC
322D00000X
Emotionally Disturbed Childrens' Residential Treatment Facility
Primary
MHL-026-627
NC
322D00000X
Emotionally Disturbed Childrens' Residential Treatment Facility
MHL-026-782
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
6603194
—
NC
05
—
6603652
—
NC
05
—
6603907
—
NC
Enumeration date
03/02/2007
Last updated
08/22/2020
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