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General NPI Number Information
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NPI Number | 1316291438
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Entity Type | Organization
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Legal Business Name | PHILLIP RAY ENTERPRISES, LLC
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Dates
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Enumeration Date | 10/29/2012
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Last Update Date | 10/29/2012
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Provider Practice Location Address
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Address Line | 5711 59TH ST
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City | SACRAMENTO
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State | CA
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Zip | 95824-1815
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Country | US
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Telephone | 916-737-0173
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Fax | 916-737-0174
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Provider Business Mailing Address
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Address Line | 5711 59TH ST
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City | SACRAMENTO
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State | CA
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Zip | 95824-1815
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Country | US
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Telephone | 916-737-0173
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Fax | 916-737-0174
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Authorized Official
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Title or Position | MANAGING MEMBER/OWNER
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Name | MR. MARVIN GIBSON
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Credential | B.A.
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Telephone | 916-761-8385
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA0005X
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Taxonomy Name | Ambulatory Family Planning Facility
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License Number | 347002410
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License Number State | CA
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