Provider Demographics
NPI:1437683737
Name:RAY, GORDON
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:
Last Name:RAY
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:PO BOX 87
Mailing Address - Street 2:
Mailing Address - City:FOWLER
Mailing Address - State:CO
Mailing Address - Zip Code:81039-0087
Mailing Address - Country:US
Mailing Address - Phone:719-263-5168
Mailing Address - Fax:719-263-5460
Practice Address - Street 1:34385 HWY 167
Practice Address - Street 2:
Practice Address - City:FOWLER
Practice Address - State:CO
Practice Address - Zip Code:81039-0087
Practice Address - Country:US
Practice Address - Phone:719-263-5168
Practice Address - Fax:719-263-5460
Is Sole Proprietor?:No
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications