MEDICARE: GRAY PHYSICAL THERAPY

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	225100000X	Physical Therapist	PT20219	CA

General Provider Information

NPI Number	:	1639302631
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAY PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	4250 FOWLER LN STE 101
Second Line	:
City	:	DIAMOND SPRINGS
State	:	CA
Zip	:	95619-9782
Country	:	US
Telephone Number	:	530-409-0677
Fax Number	:	530-295-8266

Provider Business Practice Location Address
First Line	:	4250 FOWLER LN STE 101
Second Line	:
City	:	DIAMOND SPRINGS
State	:	CA
Zip	:	95619-9782
Country	:	US
Telephone Number	:	530-409-0677
Fax Number	:	530-295-8266

Authorized Official
Title or Position	:	MPT/OWNER
Name	:	LAWRENCE A GRAY
Credential	:	MPT
Telephone Number	:	530-409-0677

Provider Enumeration Date	:	08/25/2009
Last Update Date	:	12/19/2017

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Directions to “GRAY PHYSICAL THERAPY ” Practice Location

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