Healthcare Provider Details

I. General information

NPI: 1902325574
Provider Name (Legal Business Name): JIMMY ALLAN WRIGHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2017
Last Update Date: 09/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3230 STADIUM TOWER DR
TROY AL
36082-0001
US

IV. Provider business mailing address

402 CHERRY ST
EUFAULA AL
36027-1410
US

V. Phone/Fax

Practice location:
  • Phone: 334-670-3720
  • Fax:
Mailing address:
  • Phone: 334-695-0899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: