Provider Demographics
NPI:1558680389
Name:GRAY, KERIC LESTER (LMP)
Entity type:Individual
Prefix:
First Name:KERIC
Middle Name:LESTER
Last Name:GRAY
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3624 E 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-5409
Mailing Address - Country:US
Mailing Address - Phone:509-492-0857
Mailing Address - Fax:
Practice Address - Street 1:1301 N PINES RD STE 102
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-4964
Practice Address - Country:US
Practice Address - Phone:509-922-5585
Practice Address - Fax:509-927-7336
Is Sole Proprietor?:No
Enumeration Date:2010-05-18
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60146108225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist