Basic Information
| Provider Information | |||||||||
| NPI: | 1801132071 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHLIGHT HEALTHCARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3125 POPLARWOOD CT | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276041084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197876131 | ||||||||
| FaxNumber: | 9195712932 | ||||||||
| Practice Location | |||||||||
| Address1: | 2101 GARNER RD | ||||||||
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| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276104687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197876131 | ||||||||
| FaxNumber: | 9195712932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2012 | ||||||||
| LastUpdateDate: | 06/10/2015 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9197876131 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 34D2090259 | NC | N | Laboratories | Clinical Medical Laboratory | 261QP2300X | 23029 | NC | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 34D2090259 | 01 | NC | CLIA | OTHER |