MEDICARE: MYCHAL GRAY

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	247200000X	Other Technician		NV
2	376K00000X	Nurse's Aide		NV

General Provider Information

NPI Number	:	1538782370
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MYCHAL GRAY

Provider Business Mailing Address
First Line	:	3900 DALECREST DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-1748
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1117 STONE RIVER DR
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-1601
Country	:	US
Telephone Number	:	702-773-3271
Fax Number	:

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

Provider Enumeration Date	:	05/27/2020
Last Update Date	:	05/27/2020

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Directions to “ MYCHAL GRAY ” Practice Location

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