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General NPI Number Information
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NPI Number | 1457579609
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Entity Type | Individual
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Provider Name | MR. JERRY D. GRIMES
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Gender | Male
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Dates
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Enumeration Date | 04/23/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 705 WHISPER TRL APT #204B
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City | AUSTELL
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State | GA
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Zip | 30168-7135
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Country | US
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Telephone | 678-488-5272
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Fax | 770-723-9352
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Provider Business Mailing Address
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Address Line | PO BOX 28094
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City | ATLANTA
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State | GA
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Zip | 30358-0094
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Country | US
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Telephone | 678-488-5272
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Fax | 770-723-9352
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246ZS0410X
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Taxonomy Name | Surgical Technologist
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License Number |
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License Number State |
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