Basic Information
| Provider Information | |||||||||
| NPI: | 1235335282 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHLIGHT HEALTHCARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3125 POPLARWOOD COURT | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276046445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197876131 | ||||||||
| FaxNumber: | 9195712932 | ||||||||
| Practice Location | |||||||||
| Address1: | 2101 GARNER RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276104687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198324453 | ||||||||
| FaxNumber: | 9198291357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2007 | ||||||||
| LastUpdateDate: | 11/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | CLODFELTER | ||||||||
| AuthorizedOfficialFirstName: | REYNOLDS | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9197876131 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PH.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | MHL092169 | NC | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8300527T | 05 | NC | MEDICAID |