Healthcare Provider Details

I. General information

NPI: 1275691313
Provider Name (Legal Business Name): RENE S GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 10TH AVE APT 7
PORT HURON MI
48060-2882
US

IV. Provider business mailing address

4076 WILSON DR
FORT GRATIOT MI
48059-4099
US

V. Phone/Fax

Practice location:
  • Phone: 810-388-1200
  • Fax:
Mailing address:
  • Phone: 810-388-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: