=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750276077
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JIMMIE C GRAYS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2025
-----------------------------------------------------
Last Update Date | 06/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2903 15TH AVE
-----------------------------------------------------
City | SOUTH MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53172-3031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-497-8448
-----------------------------------------------------
Fax | 262-681-3118
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5221 GALLANT FOX LN
-----------------------------------------------------
City | CALEDONIA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53402-6100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-497-8448
-----------------------------------------------------
Fax | 262-497-8448
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 0014387
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 311Z00000X
-----------------------------------------------------
Taxonomy Name | Custodial Care Facility
-----------------------------------------------------
License Number | 0014387
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------