MEDICARE: DAVID CHARLES GRAY D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	309	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	04-00092-3	OTHER	MT	WORKERS COMP
2	40240	OTHER	MT	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1265587596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID CHARLES GRAY D.C.

Provider Business Mailing Address
First Line	:	3031 S RUSSELL ST
Second Line	:	SUITE 3
City	:	MISSOULA
State	:	MT
Zip	:	59801-8523
Country	:	US
Telephone Number	:	405-549-4067
Fax Number	:	406-327-6706

Provider Business Practice Location Address
First Line	:	3031 S RUSSELL ST
Second Line	:	SUITE 3
City	:	MISSOULA
State	:	MT
Zip	:	59801-8523
Country	:	US
Telephone Number	:	405-549-4067
Fax Number	:	406-327-6706

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	09/30/2011

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