Healthcare Provider Details

I. General information

NPI: 1174795728
Provider Name (Legal Business Name): GARY LEE GREGORY ACA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2008
Last Update Date: 03/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 MALABU DR SUITE #3
LEXINGTON KY
40503-3143
US

IV. Provider business mailing address

121 MALABU DR SUITE #3
LEXINGTON KY
40503-3143
US

V. Phone/Fax

Practice location:
  • Phone: 859-278-7212
  • Fax: 859-277-3313
Mailing address:
  • Phone: 859-278-7212
  • Fax: 859-277-3313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number626
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: