MEDICARE: JIMMIE C 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	311ZA0620X	Adult Care Home Facility	0014387	WI
2	311Z00000X	Custodial Care Facility	0014387	WI

General Provider Information

NPI Number	:	1750276077
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JIMMIE C GRAYS

Provider Business Mailing Address
First Line	:	5221 GALLANT FOX LN
Second Line	:
City	:	CALEDONIA
State	:	WI
Zip	:	53402-6100
Country	:	US
Telephone Number	:	262-497-8448
Fax Number	:	262-497-8448

Provider Business Practice Location Address
First Line	:	2903 15TH AVE
Second Line	:
City	:	SOUTH MILWAUKEE
State	:	WI
Zip	:	53172-3031
Country	:	US
Telephone Number	:	262-497-8448
Fax Number	:	262-681-3118

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

Provider Enumeration Date	:	06/09/2025
Last Update Date	:	06/09/2025

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Directions to “ JIMMIE C GRAYS ” Practice Location

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