Provider Demographics
NPI:1184081374
Name:KEN GRAY COMPANY INC.
Entity type:Organization
Organization Name:KEN GRAY COMPANY INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:630-914-5065
Mailing Address - Street 1:451 MALLVIEW LN
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-2974
Mailing Address - Country:US
Mailing Address - Phone:630-914-5065
Mailing Address - Fax:
Practice Address - Street 1:451 MALLVIEW LN
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2974
Practice Address - Country:US
Practice Address - Phone:630-914-5065
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KEN GRAY COMPANY INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-01-20
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL246RM2200X, 246RP1900X, 247ZC0005X, 367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist AssistantGroup - Multi-Specialty
No246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical LaboratoryGroup - Multi-Specialty
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Multi-Specialty
No247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physicianGroup - Multi-Specialty