Provider Demographics
NPI:1164542189
Name:WRIGHT, GLEN (TECHNICAL ASSISTAN)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:
Last Name:WRIGHT
Suffix:
Gender:M
Credentials:TECHNICAL ASSISTAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 N HAMPTON RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-2387
Mailing Address - Country:US
Mailing Address - Phone:682-597-3425
Mailing Address - Fax:817-472-5832
Practice Address - Street 1:1701 N HAMPTON RD
Practice Address - Street 2:SUITE A
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2387
Practice Address - Country:US
Practice Address - Phone:682-597-3425
Practice Address - Fax:817-472-5832
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QS1200X261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic