Healthcare Provider Details

I. General information

NPI: 1710416359
Provider Name (Legal Business Name): AIMEE GRIMM OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 07/21/2022
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 ROUTE 611
SWIFTWATER PA
18370-7787
US

IV. Provider business mailing address

13904 N DALE MABRY HWY STE 200
TAMPA FL
33618-2446
US

V. Phone/Fax

Practice location:
  • Phone: 570-839-2221
  • Fax:
Mailing address:
  • Phone: 813-908-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC5401
License Number StateFL

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: