Provider Demographics
NPI:1417370545
Name:SHINELIGHT, INC
Entity Type:Organization
Organization Name:SHINELIGHT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:GIOVANNI
Authorized Official - Last Name:CREECY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-257-6406
Mailing Address - Street 1:203 ROWAN ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-4921
Mailing Address - Country:US
Mailing Address - Phone:910-257-6406
Mailing Address - Fax:
Practice Address - Street 1:203 ROWAN ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-4921
Practice Address - Country:US
Practice Address - Phone:910-257-6406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHINELIGHT, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-24
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418071Medicaid