Basic Information
Provider Information | |||||||||
NPI: | 1023778511 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WRIGHTCHOICE HEALTHCARE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | 4TH STREET CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 302 NE 4TH ST | ||||||||
Address2: |   | ||||||||
City: | WASHINGTON | ||||||||
State: | IN | ||||||||
PostalCode: | 475012725 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8124866639 | ||||||||
FaxNumber: | 8126985420 | ||||||||
Practice Location | |||||||||
Address1: | 302 NE 4TH ST | ||||||||
Address2: |   | ||||||||
City: | WASHINGTON | ||||||||
State: | IN | ||||||||
PostalCode: | 475012725 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8127893157 | ||||||||
FaxNumber: | 8126985420 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/23/2021 | ||||||||
LastUpdateDate: | 04/27/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WRIGHT | ||||||||
AuthorizedOfficialFirstName: | JESSICA | ||||||||
AuthorizedOfficialMiddleName: | ANN | ||||||||
AuthorizedOfficialTitleorPosition: | NP | ||||||||
AuthorizedOfficialTelephone: | 8124866639 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 363LF0000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.