Provider Demographics
NPI:1851597801
Name:SOUTHLIGHT HEALTHCARE
Entity Type:Organization
Organization Name:SOUTHLIGHT HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTZELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-787-6131
Mailing Address - Street 1:3125 POPLARWOOD COURT
Mailing Address - Street 2:SUITE 203
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-6445
Mailing Address - Country:US
Mailing Address - Phone:919-787-6131
Mailing Address - Fax:919-571-2932
Practice Address - Street 1:1952 SPRING DR
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-3486
Practice Address - Country:US
Practice Address - Phone:919-557-6967
Practice Address - Fax:919-557-6871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 261QM0801X, 261QM0850X, 261QM1300X, 261QM2800X
NCMHL092461251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300978Medicaid