Healthcare Provider Details

I. General information

NPI: 1386472520
Provider Name (Legal Business Name): GRIMETIME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 07/22/2024
Certification Date: 07/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 S CHESTNUT ST
WAUREGAN CT
06387-8708
US

IV. Provider business mailing address

PO BOX 35
WAUREGAN CT
06387-0035
US

V. Phone/Fax

Practice location:
  • Phone: 978-332-3401
  • Fax:
Mailing address:
  • Phone: 860-897-4438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number
License Number State

VIII. Authorized Official

Name: MUSTAPHA MBOOB
Title or Position: MANAGEMENT
Credential: M
Phone: 978-332-3401