1649436015 NPI number — LIGHTHOUSE CARE CENTER OF OCONEE

Table of content: (NPI 1649436015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649436015 NPI number — LIGHTHOUSE CARE CENTER OF OCONEE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIGHTHOUSE CARE CENTER OF OCONEE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649436015
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3100 PERIMETER PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30909-4583
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-651-0005
Provider Business Mailing Address Fax Number:
706-651-7666

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
391 WHITE ROCK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMASSEE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29686-2015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-944-9875
Provider Business Practice Location Address Fax Number:
706-651-7666
Provider Enumeration Date:
08/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
THEIS
Authorized Official First Name:
DEBBY
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
706-651-0005

Provider Taxonomy Codes

  • Taxonomy code: 261QM0855X , with the licence number:  23245800006 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 885MXH , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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