MEDICARE: DR. LEO CHARLES GRIM D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	6546	TX

General Provider Information

NPI Number	:	1750454021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEO CHARLES GRIM D.C.

Provider Business Mailing Address
First Line	:	1406 VERMONT ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77006-1040
Country	:	US
Telephone Number	:	713-522-6336
Fax Number	:	713-522-8372

Provider Business Practice Location Address
First Line	:	1406 VERMONT ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77006-1040
Country	:	US
Telephone Number	:	713-522-6336
Fax Number	:	713-522-8372

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/16/2006
Last Update Date	:	07/09/2007

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