Provider Demographics
NPI:1376602094
Name:MARK E GRAY DC CHIROPRACTIC CORP
Entity Type:Organization
Organization Name:MARK E GRAY DC CHIROPRACTIC CORP
Other - Org Name:CHIRO FITNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTIC DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:OTA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:408-720-0941
Mailing Address - Street 1:1052 E EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087
Mailing Address - Country:US
Mailing Address - Phone:408-248-7960
Mailing Address - Fax:408-554-0654
Practice Address - Street 1:150 E FREMONT AVE
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087
Practice Address - Country:US
Practice Address - Phone:408-720-0941
Practice Address - Fax:408-991-0966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23084111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ40577ZOtherBLUE SHIELD
CADC0230840Medicare PIN