Provider Demographics
NPI:1639302631
Name:GRAY PHYSICAL THERAPY
Entity Type:Organization
Organization Name:GRAY PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MPT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:530-409-0677
Mailing Address - Street 1:4250 FOWLER LN STE 101
Mailing Address - Street 2:
Mailing Address - City:DIAMOND SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95619-9782
Mailing Address - Country:US
Mailing Address - Phone:530-409-0677
Mailing Address - Fax:530-295-8266
Practice Address - Street 1:4250 FOWLER LN STE 101
Practice Address - Street 2:
Practice Address - City:DIAMOND SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95619-9782
Practice Address - Country:US
Practice Address - Phone:530-409-0677
Practice Address - Fax:530-295-8266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-25
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT20219225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty