MEDICARE: MR. KEITH C. WRIGHT SR. ICADC, CSAC, ADC-II

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	2058	NC

General Provider Information

NPI Number	:	1023258985
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEITH C. WRIGHT SR. ICADC, CSAC, ADC-II

Provider Business Mailing Address
First Line	:	230 NEW BRIDGE ST
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28540-4708
Country	:	US
Telephone Number	:	910-389-6714
Fax Number	:	910-347-4037

Provider Business Practice Location Address
First Line	:	230 NEW BRIDGE ST
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28540-4708
Country	:	US
Telephone Number	:	910-389-6714
Fax Number	:	910-347-4037

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/04/2009
Last Update Date	:	03/04/2009

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