Healthcare Provider Details

I. General information

NPI: 1700976164
Provider Name (Legal Business Name): CHARLES WAYNE GRIMSLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 NORTH AVE
GRAND JUNCTION CO
81501-6428
US

IV. Provider business mailing address

10117 HWY 65
MESA CO
81643
US

V. Phone/Fax

Practice location:
  • Phone: 970-263-5018
  • Fax:
Mailing address:
  • Phone: 970-268-5008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: