MEDICARE: JUDITH L GRIMES

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	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1841443876
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUDITH L GRIMES

Provider Business Mailing Address
First Line	:	1706 STANLEY RD
Second Line	:	SUITE 91
City	:	FORT SAM HOUSTON
State	:	TX
Zip	:	78234-7648
Country	:	US
Telephone Number	:	210-295-7618
Fax Number	:	210-295-7523

Provider Business Practice Location Address
First Line	:	1706 STANLEY RD
Second Line	:	SUITE 91
City	:	FORT SAM HOUSTON
State	:	TX
Zip	:	78234-7648
Country	:	US
Telephone Number	:	210-295-7618
Fax Number	:	210-295-7523

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

Provider Enumeration Date	:	11/04/2008
Last Update Date	:	11/04/2008

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Directions to “ JUDITH L GRIMES ” Practice Location

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