Provider Demographics
NPI:1063723476
Name:GRAY, MARK A (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:GRAY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 CALIMESA BLVD
Mailing Address - Street 2:SUITE #1
Mailing Address - City:CALIMESA
Mailing Address - State:CA
Mailing Address - Zip Code:92320
Mailing Address - Country:US
Mailing Address - Phone:909-795-4141
Mailing Address - Fax:
Practice Address - Street 1:1025 CALIMESA BLVD
Practice Address - Street 2:SUITE #1
Practice Address - City:CALIMESA
Practice Address - State:CA
Practice Address - Zip Code:92320
Practice Address - Country:US
Practice Address - Phone:909-795-4141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12416111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor