Healthcare Provider Details

I. General information

NPI: 1629722137
Provider Name (Legal Business Name): DAIJA GRAY LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2022
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9890 COUNTY FARM RD STE 2
RIVERSIDE CA
92503-3678
US

IV. Provider business mailing address

9890 COUNTY FARM RD STE 2
RIVERSIDE CA
92503-3678
US

V. Phone/Fax

Practice location:
  • Phone: 951-509-2499
  • Fax: 951-686-6630
Mailing address:
  • Phone: 951-509-2499
  • Fax: 951-686-6630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number703640
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: