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General NPI Number Information
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NPI Number | 1790587160
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Entity Type | Individual
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Provider Name | CORY RAYMOND GRIMM
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Gender | Male
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Dates
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Enumeration Date | 03/26/2025
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Last Update Date | 03/26/2025
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Provider Practice Location Address
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Address Line | 5669 TARAWA BLVD
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City | TARAWA TERRACE
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State | NC
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Zip | 28543-1325
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Country | US
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Telephone | 470-334-8279
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Fax |
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Provider Business Mailing Address
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Address Line | 5669 TARAWA BLVD
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City | TARAWA TERRACE
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State | NC
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Zip | 28543-1325
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Country | US
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Telephone |
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Fax |
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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 | 246Z00000X
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Taxonomy Name | Other Specialist/Technologist
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License Number |
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License Number State |
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