1467727941 NPI number — GRAYCO LLC

Table of content: (NPI 1467727941)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467727941 NPI number — GRAYCO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAYCO LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1467727941
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 210805
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUKE BAY
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99821-0805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-364-3584
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3100 CHANNEL DR
Provider Second Line Business Practice Location Address:
SUITE 314
Provider Business Practice Location Address City Name:
JUNEAU
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99801-7837
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-364-3584
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/15/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
GRAHAM
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
907-364-3584

Provider Taxonomy Codes

  • Taxonomy code: 171WH0202X , with the licence number:  738061 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PCG015 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: MS2458 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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