MEDICARE: COREY GRAY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1548861123
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COREY GRAY

Provider Business Mailing Address
First Line	:	1332 7TH ST
Second Line	:
City	:	WEST PORTSMOUTH
State	:	OH
Zip	:	45663-6174
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1332 7TH ST
Second Line	:
City	:	WEST PORTSMOUTH
State	:	OH
Zip	:	45663-6174
Country	:	US
Telephone Number	:	740-858-6075
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2020
Last Update Date	:	11/02/2020

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Directions to “ COREY GRAY ” Practice Location

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