Provider Demographics
NPI:1811607138
Name:GRAYBRIDGE HEALTH, NFP
Entity type:Organization
Organization Name:GRAYBRIDGE HEALTH, NFP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRAYER
Authorized Official - Suffix:JR
Authorized Official - Credentials:CEO
Authorized Official - Phone:224-360-7103
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:224-360-7103
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:224-360-7103
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174200000XOther Service ProvidersMeals
No251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherNA