Basic Information
| Provider Information | |||||||||
| NPI: | 1821234394 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | CHARLES | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11134 N STATE ROAD 77 | ||||||||
| Address2: | DULUTH CLINIC HAYWARD | ||||||||
| City: | HAYWARD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548435325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156345505 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11134 N STATE ROAD 77 | ||||||||
| Address2: | DULUTH CLINIC HAYWARD | ||||||||
| City: | HAYWARD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548435325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156345505 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2009 | ||||||||
| LastUpdateDate: | 01/05/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 9807 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.