1861123929 NPI number — TODD JAMES GRAY

Table of content: TODD JAMES GRAY (NPI 1861123929)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861123929 NPI number — TODD JAMES GRAY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAY
Provider First Name:
TODD
Provider Middle Name:
JAMES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1861123929
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5538 MILLER CREEK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA PORTE CITY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50651-2140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-269-8709
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 ROCKY MOUNTAIN AVE STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOVELAND
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80538-9004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-624-1800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/20/2022

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: 363AS0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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