Provider Demographics
NPI:1477063923
Name:GRAY RESIDENTIAL SERVICES, LLC
Entity Type:Organization
Organization Name:GRAY RESIDENTIAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-854-5141
Mailing Address - Street 1:9660 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-7641
Mailing Address - Country:US
Mailing Address - Phone:317-854-5141
Mailing Address - Fax:317-854-4801
Practice Address - Street 1:9660 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-7641
Practice Address - Country:US
Practice Address - Phone:317-854-5141
Practice Address - Fax:317-854-4801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-10
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300009019Medicaid