Healthcare Provider Details

I. General information

NPI: 1962914036
Provider Name (Legal Business Name): ALEX RAMON WRIGHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2017
Last Update Date: 10/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 S CAROLINA RD
EASTOVER SC
29044-5052
US

IV. Provider business mailing address

348 CHAPELWHITE RD
IRMO SC
29063-2607
US

V. Phone/Fax

Practice location:
  • Phone: 803-299-6627
  • Fax:
Mailing address:
  • Phone: 803-439-4495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.019623
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: