Healthcare Provider Details

I. General information

NPI: 1700241551
Provider Name (Legal Business Name): KEN GRAY COMPANY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2015
Last Update Date: 12/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 MALLVIEW LN
BOLINGBROOK IL
60440-2974
US

IV. Provider business mailing address

451 MALLVIEW LN
BOLINGBROOK IL
60440-2974
US

V. Phone/Fax

Practice location:
  • Phone: 630-914-5065
  • Fax:
Mailing address:
  • Phone: 630-914-5065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number1301356
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number5731DV
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. KENNETH GRAY SR.
Title or Position: PRESIDENT/ CLINICAL DIRECTOR
Credential:
Phone: 630-914-5065