Healthcare Provider Details

I. General information

NPI: 1255369013
Provider Name (Legal Business Name): ROGER D GRIMM ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3813 S. MADISON ST.
MUNCIE IN
47302
US

IV. Provider business mailing address

1470 E. STATE ST.
ALBANY IN
47320
US

V. Phone/Fax

Practice location:
  • Phone: 765-751-3362
  • Fax:
Mailing address:
  • Phone: 765-789-6178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000488A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: