MEDICARE: TIMOTHY GRIMSLEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist	2215	UT

General Provider Information

NPI Number	:	1487413423
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY GRIMSLEY

Provider Business Mailing Address
First Line	:	1576 W 8295 S
Second Line	:
City	:	WEST JORDAN
State	:	UT
Zip	:	84088-8231
Country	:	US
Telephone Number	:	801-381-9481
Fax Number	:

Provider Business Practice Location Address
First Line	:	8539 S REDWOOD RD STE C
Second Line	:
City	:	WEST JORDAN
State	:	UT
Zip	:	84088-5250
Country	:	US
Telephone Number	:	801-919-4657
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2024
Last Update Date	:	03/13/2024

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Directions to “ TIMOTHY GRIMSLEY ” Practice Location

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