Healthcare Provider Details

I. General information

NPI: 1659017440
Provider Name (Legal Business Name): LAUREN GRIMM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2022
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BLYTHE BLVD
CHARLOTTE NC
28203-5812
US

IV. Provider business mailing address

1000 BLYTHE BLVD
CHARLOTTE NC
28203-5812
US

V. Phone/Fax

Practice location:
  • Phone: 704-381-2000
  • Fax:
Mailing address:
  • Phone: 704-381-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberRTL24-0855
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: