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General NPI Number Information
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NPI Number | 1861775744
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Entity Type | Individual
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Provider Name | STEVE R GRAYSON O.T.R.
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Gender | Male
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Dates
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Enumeration Date | 09/27/2011
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Last Update Date | 09/30/2011
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Provider Practice Location Address
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Address Line | 123 W MAIN ST
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City | HOMER
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State | LA
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Zip | 71040-4435
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Country | US
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Telephone | 318-927-4987
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Fax | 318-927-4987
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Provider Business Mailing Address
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Address Line | 207 N SERVICE RD E
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City | RUSTON
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State | LA
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Zip | 71270-2805
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Country | US
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Telephone | 318-927-4987
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Fax | 318-927-4987
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | Z11040
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License Number State | LA
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