Provider Demographics
NPI:1053988949
Name:RAY, BRIAN KEITH
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:RAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 IRIS ROSE CT
Mailing Address - Street 2:
Mailing Address - City:ROSENBERG
Mailing Address - State:TX
Mailing Address - Zip Code:77469-1825
Mailing Address - Country:US
Mailing Address - Phone:713-817-5413
Mailing Address - Fax:
Practice Address - Street 1:403 IRIS ROSE CT
Practice Address - Street 2:
Practice Address - City:ROSENBERG
Practice Address - State:TX
Practice Address - Zip Code:77469-1825
Practice Address - Country:US
Practice Address - Phone:713-817-5413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14282976172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver