=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972996668
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WRIGHT SURGICAL ASSISTANT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2015
-----------------------------------------------------
Last Update Date | 03/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4100 PERIDOT DR
-----------------------------------------------------
City | VA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23456-5804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-412-8017
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4100 PERIDOT DR
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23456-5804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CERTIFIED SURGICAL ASSISTANT
-----------------------------------------------------
Name | JOHN ROGER WRIGHT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-412-8017
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 1212
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number | 1212
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------