Provider Demographics
NPI:1245801117
Name:WRIGHT, BRANDON SR
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:WRIGHT
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43864 EUREKA DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-1290
Mailing Address - Country:US
Mailing Address - Phone:586-788-9102
Mailing Address - Fax:
Practice Address - Street 1:13854 LAKESIDE CIR STE 305
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1443
Practice Address - Country:US
Practice Address - Phone:248-562-5096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center