=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629592175
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHY U ACADEMY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2017
-----------------------------------------------------
Last Update Date | 06/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1226 MARKET AVE N
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44714-2604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-607-0529
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6384 HOLLYRIDGE ST NW
-----------------------------------------------------
City | NORTH CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44720-9402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD/OWNER
-----------------------------------------------------
Name | DR. MICHAEL G GRIMES
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 330-607-0529
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 35077014G
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------