Provider Demographics
NPI:1912190372
Name:BOWENS, GRADY
Entity Type:Individual
Prefix:MR
First Name:GRADY
Middle Name:
Last Name:BOWENS
Suffix:
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 1:3211 EASTWAY DR STE 13
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-6679
Mailing Address - Country:US
Mailing Address - Phone:704-568-6760
Mailing Address - Fax:704-568-7059
Practice Address - Street 1:3211 EASTWAY DR STE 13
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-6679
Practice Address - Country:US
Practice Address - Phone:704-568-6760
Practice Address - Fax:704-568-7059
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1336156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8802016Medicaid