Provider Demographics
NPI:1558377168
Name:GRAY, JON R (DC)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:R
Last Name:GRAY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13125 W PERSIMMON LN
Mailing Address - Street 2:STE. 175
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-2086
Mailing Address - Country:US
Mailing Address - Phone:208-854-0600
Mailing Address - Fax:208-375-5545
Practice Address - Street 1:13125 W PERSIMMON LN
Practice Address - Street 2:STE. 175
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-2086
Practice Address - Country:US
Practice Address - Phone:208-854-0600
Practice Address - Fax:208-375-5545
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA931111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010029829OtherBLUE SHIELD PROVIDER ID
IDC-1849OtherBLUE CROSS PROVIDER ID
ID000010029829OtherBLUE SHIELD PROVIDER ID