=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790231983
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANRAI GRAVELY D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2016
-----------------------------------------------------
Last Update Date | 08/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1602 E RIVERSIDE DR
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78741-1006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-710-8493
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8503 DAVIS OAKS TRL
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78748-6582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-794-3743
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 13225
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------