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General NPI Number Information
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NPI Number | 1245553502
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Entity Type | Organization
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Legal Business Name | SHANNON GRAY
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Dates
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Enumeration Date | 03/01/2010
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Last Update Date | 03/01/2010
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Provider Practice Location Address
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Address Line | 1111 S STAPLEY DR SUITE 111
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City | MESA
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State | AZ
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Zip | 85204-5059
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Country | US
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Telephone | 480-398-1220
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Fax | 480-398-1230
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Provider Business Mailing Address
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Address Line | 212 W SUPERSTITION BLVD SUITE 101
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City | APACHE JUNCTION
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State | AZ
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Zip | 85120-4127
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Country | US
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Telephone | 480-983-4200
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Fax | 480-983-4317
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Authorized Official
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Title or Position | ADMINISTRATOR/OWNER
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Name | MISS SHANNON GRAY
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Credential |
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Telephone | 480-983-4200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 36286
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License Number State | AZ
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