Healthcare Provider Details

I. General information

NPI: 1962556803
Provider Name (Legal Business Name): SOUTHLIGHT HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 12/13/2022
Certification Date: 11/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 GARNER RD
RALEIGH NC
27610-0114
US

IV. Provider business mailing address

3125 POPLARWOOD CT STE 203
RALEIGH NC
27604-6445
US

V. Phone/Fax

Practice location:
  • Phone: 919-787-6131
  • Fax: 919-571-2932
Mailing address:
  • Phone: 919-787-6131
  • Fax: 919-571-2932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ADAM HARTZELL
Title or Position: CEO
Credential:
Phone: 919-787-6131