Provider Demographics
NPI:1740884279
Name:GRAYER, KENNETH J JR
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:J
Last Name:GRAYER
Suffix:JR
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 1:520 E LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-2923
Mailing Address - Country:US
Mailing Address - Phone:662-346-3883
Mailing Address - Fax:
Practice Address - Street 1:520 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-2923
Practice Address - Country:US
Practice Address - Phone:662-346-3883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver