Provider Demographics
NPI:1760243257
Name:GRAY, CLIFFORD HARRISON JR (LAB OWNER)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:HARRISON
Last Name:GRAY
Suffix:JR
Gender:M
Credentials:LAB OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 SW VALLEY CT
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-6975
Mailing Address - Country:US
Mailing Address - Phone:612-889-4551
Mailing Address - Fax:
Practice Address - Street 1:133 SW PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34984-5042
Practice Address - Country:US
Practice Address - Phone:772-732-2028
Practice Address - Fax:772-732-2026
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory