Provider Demographics
NPI:1336251347
Name:GRAY, KEVIN LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:LEE
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 1:207 E OAK ST
Mailing Address - Street 2:
Mailing Address - City:MAHOMET
Mailing Address - State:IL
Mailing Address - Zip Code:61853-9213
Mailing Address - Country:US
Mailing Address - Phone:217-586-3886
Mailing Address - Fax:217-586-4848
Practice Address - Street 1:207 E OAK ST
Practice Address - Street 2:
Practice Address - City:MAHOMET
Practice Address - State:IL
Practice Address - Zip Code:61853-9213
Practice Address - Country:US
Practice Address - Phone:217-586-3886
Practice Address - Fax:217-586-4848
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038004162111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL663960Medicare ID - Type UnspecifiedPROVIDER NUMBER