Basic Information
| Provider Information | |||||||||
| NPI: | 1255537205 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHLIGHT, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3125 POPLARWOOD CT STE 203 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276046445 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2101 GARNER RD STE 113 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276104687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197876131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2007 | ||||||||
| LastUpdateDate: | 05/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | BARBER | ||||||||
| AuthorizedOfficialFirstName: | FRANK | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIR HIM | ||||||||
| AuthorizedOfficialTelephone: | 9197876131 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 8300527G | 05 | NY | MEDICAID |