Provider Demographics
NPI:1720336324
Name:KELLIE M GRAY PC
Entity Type:Organization
Organization Name:KELLIE M GRAY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:623-980-9508
Mailing Address - Street 1:17215 N 72ND DR
Mailing Address - Street 2:SUITE A105
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8558
Mailing Address - Country:US
Mailing Address - Phone:623-334-4056
Mailing Address - Fax:623-334-4060
Practice Address - Street 1:17215 N 72ND DR
Practice Address - Street 2:SUITE A105
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8558
Practice Address - Country:US
Practice Address - Phone:623-334-4056
Practice Address - Fax:623-334-4060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4710111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ DC 4710OtherMEDICARE PROVIDER NUMBER
AZ1700842838OtherNPI ASSOCIATED WITH MY SSN
AZ4710OtherCHIROPRACTIC LICENSE NUMBER
AZ1700842838OtherNPI ASSOCIATED WITH MY SSN