Healthcare Provider Details

I. General information

NPI: 1326020348
Provider Name (Legal Business Name): EVAN GRAY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 06/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6975 BURLINGTON PIKE
FLORENCE KY
41042-1618
US

IV. Provider business mailing address

12500 REED HARTMAN HWY SUITE 200
CINCINNATI OH
45241-1892
US

V. Phone/Fax

Practice location:
  • Phone: 513-605-5000
  • Fax:
Mailing address:
  • Phone: 513-605-2700
  • Fax: 513-605-2731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number100547
License Number StateKY

VIII. Authorized Official

Name: MR. GREG MILLER
Title or Position: CHEIF OPERATING OFFICER
Credential:
Phone: 513-605-2700