Provider Demographics
NPI:1316291438
Name:PHILLIP RAY ENTERPRISES, LLC
Entity type:Organization
Organization Name:PHILLIP RAY ENTERPRISES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:916-761-8385
Mailing Address - Street 1:5711 59TH ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95824-1815
Mailing Address - Country:US
Mailing Address - Phone:916-737-0173
Mailing Address - Fax:916-737-0174
Practice Address - Street 1:5711 59TH ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95824-1815
Practice Address - Country:US
Practice Address - Phone:916-737-0173
Practice Address - Fax:916-737-0174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA347002410261QA0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility