Provider Demographics
NPI:1891826624
Name:WRIGHT, GARY RANDALL SR
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:RANDALL
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 1:2122 BRADLEY RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1260
Mailing Address - Country:US
Mailing Address - Phone:815-399-6312
Mailing Address - Fax:
Practice Address - Street 1:810 N ALPINE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3673
Practice Address - Country:US
Practice Address - Phone:815-395-9567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0887237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist