Healthcare Provider Details

I. General information

NPI: 1730681727
Provider Name (Legal Business Name): SHANNON GRIMES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1603 S MUSKOGEE AVE
TAHLEQUAH OK
74464-5430
US

IV. Provider business mailing address

1603 S MUSKOGEE AVE
TAHLEQUAH OK
74464-5430
US

V. Phone/Fax

Practice location:
  • Phone: 918-453-9355
  • Fax: 918-871-4801
Mailing address:
  • Phone: 918-453-9355
  • Fax: 918-871-4801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3684
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierV082185600
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerDRIVERS LICENCE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: