Healthcare Provider Details

I. General information

NPI: 1720336324
Provider Name (Legal Business Name): KELLIE M GRAY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17215 N 72ND DR SUITE A105
GLENDALE AZ
85308-8558
US

IV. Provider business mailing address

17215 N 72ND DR SUITE A105
GLENDALE AZ
85308-8558
US

V. Phone/Fax

Practice location:
  • Phone: 623-334-4056
  • Fax: 623-334-4060
Mailing address:
  • Phone: 623-334-4056
  • Fax: 623-334-4060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4710
License Number StateAZ

VIII. Authorized Official

Name: KELLIE M GRAY
Title or Position: PRESIDENT/CEO
Credential: DC
Phone: 623-980-9508