1730681727 NPI number — SHANNON GRIMES

Table of content: SHANNON GRIMES (NPI 1730681727)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730681727 NPI number — SHANNON GRIMES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRIMES
Provider First Name:
SHANNON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730681727
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1603 S MUSKOGEE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAHLEQUAH
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74464-5430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-453-9355
Provider Business Mailing Address Fax Number:
918-871-4801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1603 S MUSKOGEE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAHLEQUAH
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74464-5430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-453-9355
Provider Business Practice Location Address Fax Number:
918-871-4801
Provider Enumeration Date:
03/06/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3684 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: V082185600 . This is a "DRIVERS LICENCE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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