Basic Information
| Provider Information | |||||||||
| NPI: | 1447650478 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHLIGHT HEALTHCARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3125 POPLARWOOD CT STE 203 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276046445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526377204 | ||||||||
| FaxNumber: | 9195712932 | ||||||||
| Practice Location | |||||||||
| Address1: | 3125 POPLARWOOD CT STE 203 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276046445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526377204 | ||||||||
| FaxNumber: | 9195712932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2014 | ||||||||
| LastUpdateDate: | 04/14/2015 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2526377204 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | NC | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1316268345 | 05 | NC | MEDICAID | 1932300019 | 01 | NC | COMMERICAL | OTHER |