MEDICARE: MARK E GRAY DC CHIROPRACTIC CORP

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	18229	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ405772	OTHER	CA	BLUE SHIELD

General Provider Information

NPI Number	:	1912079971
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK E GRAY DC CHIROPRACTIC CORP

Provider Business Mailing Address
First Line	:	1052 E EL CAMINO REAL
Second Line	:
City	:	SUNNYVALE
State	:	CA
Zip	:	94087
Country	:	US
Telephone Number	:	408-248-7960
Fax Number	:	408-554-0654

Provider Business Practice Location Address
First Line	:	1052 E EL CAMINO REAL
Second Line	:
City	:	SUNNYVALE
State	:	CA
Zip	:	94087
Country	:	US
Telephone Number	:	408-248-7960
Fax Number	:	408-554-0654

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARK E GRAY
Credential	:	DC
Telephone Number	:	408-248-7960

Provider Enumeration Date	:	11/14/2006
Last Update Date	:	10/12/2007

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