Healthcare Provider Details

I. General information

NPI: 1912718974
Provider Name (Legal Business Name): SARA GRAY ICP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2025
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6649 CREEKSIDE WAY
FAIRFIELD TOWNSHIP OH
45011-7939
US

IV. Provider business mailing address

680 GLENNA DR
FAIRFIELD OH
45014-2719
US

V. Phone/Fax

Practice location:
  • Phone: 901-417-0200
  • Fax:
Mailing address:
  • Phone: 513-907-8880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: