Provider Demographics
NPI:1174006787
Name:GRAY, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:GRAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 ROSWELL AVE APT 211
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-5906
Mailing Address - Country:US
Mailing Address - Phone:520-904-0098
Mailing Address - Fax:
Practice Address - Street 1:1250 BELLFLOWER BLVD KINESIOLOGY BUILDING RM 105
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90840-0001
Practice Address - Country:US
Practice Address - Phone:562-985-8286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-10
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA295205225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist