Provider Demographics
NPI:1316268345
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 CT
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 1:2101 GARNER RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-0114
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:2010-06-14
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251B00000X
261QM1300X, 261QM2800X, 261QR0405X, 251S00000X, 261QM0850X, 261QM1300X, 261QM2800X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadoneGroup - Multi-Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1053465997Medicaid