Healthcare Provider Details

I. General information

NPI: 1235204603
Provider Name (Legal Business Name): SOUTHERN LIGHT OSTEOPATHIC WELLNESS & HEALTHCARE ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4164 COASTAL HWY US 17 S
RICHMOND HILL GA
31324
US

IV. Provider business mailing address

PO BOX 1979
RICHMOND HILL GA
31324-1979
US

V. Phone/Fax

Practice location:
  • Phone: 912-756-7014
  • Fax: 912-756-7037
Mailing address:
  • Phone: 912-756-7014
  • Fax: 912-756-7037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number042536
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number042536
License Number StateGA

VIII. Authorized Official

Name: DR. THOMAS RAYMOND BYRNES JR.
Title or Position: MEDICAL DIRECTOR
Credential: D.O.
Phone: 972-756-7014