1285655654 NPI number — RUTH ELLEN GRAY

Table of content: RUTH ELLEN GRAY (NPI 1285655654)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285655654 NPI number — RUTH ELLEN GRAY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAY
Provider First Name:
RUTH
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285655654
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2050 S BLOSSER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA MARIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93458-7310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-361-8028
Provider Business Mailing Address Fax Number:
805-361-8097

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 TEJAS PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NIPOMO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93444-9123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-929-3211
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC 17933 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: W1508 . This is a "MEDICARE GROUP NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: FHC03884F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1841217866 . This is a "NCMC NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1376560151 . This is a "GUADALUPE NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1447277355 . This is a "CHCCC, SANTA MARIA 1" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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