Healthcare Provider Details

I. General information

NPI: 1629376504
Provider Name (Legal Business Name): WRIGHT DREAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2011
Last Update Date: 03/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 S SHERIDAN ST
SOUTH BEND IN
46619-2935
US

IV. Provider business mailing address

706 S SHERIDAN ST
SOUTH BEND IN
46619-2935
US

V. Phone/Fax

Practice location:
  • Phone: 574-300-2820
  • Fax:
Mailing address:
  • Phone: 574-300-2820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number1350228558
License Number StateIN

VIII. Authorized Official

Name: MISS TAMEKA LA 'COLE WRIGHT
Title or Position: OWNER
Credential:
Phone: 574-300-2820