Healthcare Provider Details

I. General information

NPI: 1073535845
Provider Name (Legal Business Name): GARY GRAY PHYSICAL THERAPY CLINIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 03/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2408 MOMENTUM PL
CHICAGO IL
60689-0001
US

IV. Provider business mailing address

1801 W MAUMEE ST SUITE 125
ADRIAN MI
49221-1291
US

V. Phone/Fax

Practice location:
  • Phone: 877-255-4322
  • Fax:
Mailing address:
  • Phone: 517-264-6141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateMI

VIII. Authorized Official

Name: ERIC C WARNER
Title or Position: PRESIDENT
Credential: PT
Phone: 312-640-0329