Provider Demographics
NPI:1932300019
Name:SOUTHLIGHT HEALTHCARE
Entity Type:Organization
Organization Name:SOUTHLIGHT HEALTHCARE
Other - Org Name:SOUTHLIGHT, INC.
Other - Org Type:Former Legal Business Name
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 CT STE 203
Mailing Address - Street 2:
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 1:2101 GARNER RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-4687
Practice Address - Country:US
Practice Address - Phone:919-787-6131
Practice Address - Fax:919-571-2932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
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
NC6005406Medicaid
NC6005993Medicaid
NC6005404Medicaid