Basic Information
| Provider Information | |||||||||
| NPI: | 1215699111 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 604050 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282604050 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 PINEVIEW DR STE 205 | ||||||||
| Address2: | |||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272843814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363293295 | ||||||||
| FaxNumber: | 3363555204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2021 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | L005641 | NC | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.