Provider Demographics
NPI:1235204603
Name:SOUTHERN LIGHT OSTEOPATHIC WELLNESS & HEALTHCARE ASSOCIATES, INC.
Entity Type:Organization
Organization Name:SOUTHERN LIGHT OSTEOPATHIC WELLNESS & HEALTHCARE ASSOCIATES, INC.
Other - Org Name:REDICARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:BYRNES
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:972-756-7014
Mailing Address - Street 1:PO BOX 1979
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-1979
Mailing Address - Country:US
Mailing Address - Phone:912-756-7014
Mailing Address - Fax:912-756-7037
Practice Address - Street 1:4164 COASTAL HWY US 17 S
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324
Practice Address - Country:US
Practice Address - Phone:912-756-7014
Practice Address - Fax:912-756-7037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042536261QM2500X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Not Answered261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care