Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 4772 | TX |
NPI | 1578815403 |
---|---|
Provider Name | Lance Ray Wright |
First Address | Dallas, TX 75254-7019 |
Second Address | Dallas, TX 75254-7019 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/10/2012 |
Last Update Date | 02/10/2012 |