Organization
COLLEGE LAKES
Active
Parent organization
SHINELIGHT, INC.
Organization subpart
Yes
Provider details
NPI number
Legal business name
SHINELIGHT, INC.
Authorized official
NIKKI GIOVANNI CREECY (CEO)
(910) 257-6406
Entity
Organization
Contact information
Practice address
5104 FLATROCK DRIVE, FAYETTEVILLE, NC 28311
(910) 488-6323
(910) 223-2180
Mailing address
5104 FLATROCK DRIVE, FAYETTEVILLE, NC 28311
(910) 257-6406
Taxonomy
Speciality
Code
Description
License number
State
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
Primary
MHL-047-133
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
3418071
—
NC
Enumeration date
01/20/2014
Last updated
04/21/2021
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