MEDICARE: LAKESHIA GRAYS

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	101Y00000X	Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	824551386	OTHER	FL	WIG MANUFACTURER

General Provider Information

NPI Number	:	1497347074
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAKESHIA GRAYS

Provider Business Mailing Address
First Line	:	PO BOX 12166
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33101-2166
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7155 NW 179TH ST APT 110
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33015-6112
Country	:	US
Telephone Number	:	786-694-8956
Fax Number	:

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

Provider Enumeration Date	:	02/05/2021
Last Update Date	:	02/05/2021

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Directions to “ LAKESHIA GRAYS ” Practice Location

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