1619254844 NPI number — TOVARA GRAY

Table of content: TOVARA GRAY (NPI 1619254844)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619254844 NPI number — TOVARA GRAY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAY
Provider First Name:
TOVARA
Provider Middle Name:
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:
1619254844
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
380 SUWANNEE TRAIL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOWLING GREEN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42103-7956
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-901-5000
Provider Business Mailing Address Fax Number:
270-842-5268

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
512 BOWLING GREEN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCOTTSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42164-8303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-237-4481
Provider Business Practice Location Address Fax Number:
270-237-4858
Provider Enumeration Date:
11/16/2011

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: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 30604011 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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