=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689932006
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEO C GRIM P C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2012
-----------------------------------------------------
Last Update Date | 04/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1406 VERMONT ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77006-1040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-562-4030
-----------------------------------------------------
Fax | 713-522-8372
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1406 VERMONT ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77006-1040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-562-4030
-----------------------------------------------------
Fax | 713-522-8372
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LEO CHARLES GRIM
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 713-562-4030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 6546
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------