Light House Group

Primary specialty

Emotionally Disturbed Childrens' Residential Treatment FacilityTaxonomy code 322D00000X

License

MHL-026-627 Issued in NC

Legal business name

LIGHT HOUSE GROUP

Practice address

206 Wapiti Dr
108 Ashton PL
Spring Lake, NC 28390-1530

Phone

(910) 497-0299

Fax

(910) 497-0297

NPI assigned

Mar 2, 2007

Last updated

Aug 22, 2020By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Charles Davenport

Title

President

Phone

(910) 497-0299

Specialties & licenses 3

Addresses

Other identifiers 3

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1172793600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1225166069",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "408 HARRELL ST",
            "address_2": "PO BOX 1089",
            "city": "SPRING LAKE",
            "state": "NC",
            "postal_code": "283903607",
            "telephone_number": "910-497-0299",
            "fax_number": "910-497-0297"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "206 WAPITI DR",
            "address_2": "108 ASHTON PL",
            "city": "SPRING LAKE",
            "state": "NC",
            "postal_code": "283901530",
            "telephone_number": "910-497-0299",
            "fax_number": "910-497-0297"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LIGHT HOUSE GROUP",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-02",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "DAVENPORT",
        "authorized_official_first_name": "CHARLES",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "910-497-0299"
    },
    "taxonomies": [
        {
            "code": "322D00000X",
            "taxonomy_group": "",
            "desc": "Residential Treatment Facility, Emotionally Disturbed Children",
            "state": "NC",
            "license": "MHL -026-805",
            "primary": false
        },
        {
            "code": "322D00000X",
            "taxonomy_group": "",
            "desc": "Residential Treatment Facility, Emotionally Disturbed Children",
            "state": "NC",
            "license": "MHL-026-782",
            "primary": false
        },
        {
            "code": "322D00000X",
            "taxonomy_group": "",
            "desc": "Residential Treatment Facility, Emotionally Disturbed Children",
            "state": "NC",
            "license": "MHL-026-627",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "6603194",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "6603907",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "6603652",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Emotionally Disturbed Childrens' Residential Treatment Facility in Spring Lake, NC
• Providers in Spring Lake, NC by specialty
• Emotionally Disturbed Childrens' Residential Treatment Facility in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.