Organization
GUARDIAN LIGHT GROUP HOME
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. ROBERTHA M POWERS (OWNER)
(910) 864-3163
Entity
Organization
Contact information
Practice address
1294 HALLSBORO RD S, HALLSBORO, NC 28442-9276
(910) 864-3163
Mailing address
PO BOX 1877, WHITEVILLE, NC 28472-1877
(910) 864-3163
(910) 864-3163
Taxonomy
Speciality
Code
Description
License number
State
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
Primary
MHL-024-056
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
6603682
—
NC
Enumeration date
03/28/2007
Last updated
07/25/2007
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