=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891826624
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. GARY RANDALL WRIGHT SR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 810 N ALPINE RD
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61107-3673
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-395-9567
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2122 BRADLEY RD
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61107-1260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-399-6312
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237700000X
-----------------------------------------------------
Taxonomy Name | Hearing Instrument Specialist
-----------------------------------------------------
License Number | 0887
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------