Provider Demographics
NPI:1285655654
Name:GRAY, RUTH ELLEN
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:ELLEN
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 S BLOSSER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7310
Mailing Address - Country:US
Mailing Address - Phone:805-361-8028
Mailing Address - Fax:805-361-8097
Practice Address - Street 1:150 TEJAS PL
Practice Address - Street 2:
Practice Address - City:NIPOMO
Practice Address - State:CA
Practice Address - Zip Code:93444-9123
Practice Address - Country:US
Practice Address - Phone:805-929-3211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 17933111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
W1508OtherMEDICARE GROUP NUMBER
CAFHC03884FMedicaid
CA1841217866OtherNCMC NPI
CA1376560151OtherGUADALUPE NPI
CA1447277355OtherCHCCC, SANTA MARIA 1
CAFHC03884FMedicaid
CA1841217866OtherNCMC NPI
CA051847Medicare Oscar/Certification