Provider Demographics
NPI:1487236535
Name:WRIGHT, CORNELIUS ANTONIO
Entity type:Individual
Prefix:
First Name:CORNELIUS
Middle Name:ANTONIO
Last Name:WRIGHT
Suffix:
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 1:2141 MOCKINGBIRD LOOP
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:SC
Mailing Address - Zip Code:29536-8044
Mailing Address - Country:US
Mailing Address - Phone:910-610-8705
Mailing Address - Fax:888-919-1981
Practice Address - Street 1:2141 MOCKINGBIRD LOOP
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536-8044
Practice Address - Country:US
Practice Address - Phone:910-610-8705
Practice Address - Fax:888-919-1981
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver