Basic Information
| Provider Information | |||||||||
| NPI: | 1467917559 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | SULLIVAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 700688 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782700688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103183007 | ||||||||
| FaxNumber: | 2104680682 | ||||||||
| Practice Location | |||||||||
| Address1: | 2203 TIMBERLOCH PL STE 132 | ||||||||
| Address2: | |||||||||
| City: | THE WOODLANDS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773801105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004045060 | ||||||||
| FaxNumber: | 8663133397 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2019 | ||||||||
| LastUpdateDate: | 11/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111NR0400X | 14065 | TX | Y | Chiropractic Providers | Chiropractor | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 14065 | 01 | TX | CHIROPRACTIC LICENSE | OTHER | 230101182 | 01 | MI | CHIROPRACTIC LICENSE | OTHER | CH12698 | 01 | FL | CHIROPRACTIC LICENSE | OTHER | CH030228 | 01 | DC | CHIROPRACTIC LICENSE | OTHER |