=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801172259
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AIMEE K. GRAY, OD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2011
-----------------------------------------------------
Last Update Date | 04/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300A FAUNCE CORNER RD SUITE 101
-----------------------------------------------------
City | NORTH DARTMOUTH
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02747-1280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-994-8092
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300A FAUNCE CORNER RD SUITE 101
-----------------------------------------------------
City | NORTH DARTMOUTH
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02747-1280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-995-8200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. AIMEE GRAY PICKETT
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 508-994-8092
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 4197
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4197
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------