Healthcare Provider Details

I. General information

NPI: 1710766944
Provider Name (Legal Business Name): COLE IVAN GRIMES DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2023
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date: 04/27/2026
Reactivation Date: 08/10/2026

III. Provider practice location address

3551 ROGER BROOKE DR
FORT SAM HOUSTON TX
78234-4504
US

IV. Provider business mailing address

1614 RAINY BRK
SCHERTZ TX
78154-3067
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-7500
  • Fax:
Mailing address:
  • Phone: 940-782-1117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: