1730682675 NPI number — RADIANT LIGHT BEHAVIORAL CONCEPTS, LLC

Table of content: (NPI 1730682675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730682675 NPI number — RADIANT LIGHT BEHAVIORAL CONCEPTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RADIANT LIGHT BEHAVIORAL CONCEPTS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730682675
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 W MAIN AVE # 2752
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GASTONIA
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28052-4173
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-447-0931
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
625 E 2ND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GASTONIA
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28054-0470
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-447-0931
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/16/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LONG
Authorized Official First Name:
OMAR
Authorized Official Middle Name:
S
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
908-447-0931

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  2174 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: C001640 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 2436 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)