Provider Demographics
NPI:1538378757
Name:GRAY CLINIC OF CHIROPRACTIC, LTD
Entity type:Organization
Organization Name:GRAY CLINIC OF CHIROPRACTIC, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, DR.
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:217-586-3886
Mailing Address - Street 1:207 E. OAK ST
Mailing Address - Street 2:
Mailing Address - City:MAHOMET
Mailing Address - State:IL
Mailing Address - Zip Code:61853
Mailing Address - Country:US
Mailing Address - Phone:217-586-3886
Mailing Address - Fax:217-586-4848
Practice Address - Street 1:207 E. OAK ST
Practice Address - Street 2:
Practice Address - City:MAHOMET
Practice Address - State:IL
Practice Address - Zip Code:61853
Practice Address - Country:US
Practice Address - Phone:217-586-3886
Practice Address - Fax:217-586-4848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL229436OtherHEALTHLINK PIN
IL1015033OtherBLUE CROSS PIN
IL1015033OtherBLUE CROSS PIN