1609028810 NPI number — MR. JOHN WESLEY WRIGHT JR. CSAC

Table of content: MR. JOHN WESLEY WRIGHT JR. CSAC (NPI 1609028810)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609028810 NPI number — MR. JOHN WESLEY WRIGHT JR. CSAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WRIGHT
Provider First Name:
JOHN
Provider Middle Name:
WESLEY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
CSAC
Provider Gender Code:
M

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:
1609028810
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4383 S 27TH ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-871-8883
Provider Business Mailing Address Fax Number:
414-871-8950

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4383 S. 27TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-871-8883
Provider Business Practice Location Address Fax Number:
414-871-8950
Provider Enumeration Date:
10/21/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  11350-132 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 39393900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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