Provider Demographics
NPI:1639445968
Name:GRAY, JIMMY LEE SR
Entity Type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:LEE
Last Name:GRAY
Suffix:SR
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 1:2851 S DECATUR BLVD
Mailing Address - Street 2:APT 228
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-8986
Mailing Address - Country:US
Mailing Address - Phone:702-366-7719
Mailing Address - Fax:
Practice Address - Street 1:2851 S DECATUR BLVD
Practice Address - Street 2:APT 228
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-8986
Practice Address - Country:US
Practice Address - Phone:702-366-7719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner