Basic Information
| Provider Information | |||||||||
| NPI: | 1285655654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | RUTH | ||||||||
| MiddleName: | ELLEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2050 S BLOSSER RD | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934587310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8053618028 | ||||||||
| FaxNumber: | 8053618097 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 TEJAS PL | ||||||||
| Address2: | |||||||||
| City: | NIPOMO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934449123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059293211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 06/11/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | DC 17933 | CA | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | W1508 | 01 | MEDICARE GROUP NUMBER | OTHER | FHC03884F | 05 | CA | MEDICAID | 1841217866 | 01 | CA | NCMC NPI | OTHER | 1376560151 | 01 | CA | GUADALUPE NPI | OTHER | 1447277355 | 01 | CA | CHCCC, SANTA MARIA 1 | OTHER |