Provider Information for 1265897656
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MICHELLE GRIMMER
Sex: Female
NPI: 1265897656
Last Updated: 2018-03-17
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| NPI | 1265897656 | ||||||||
| Enumeration Date | 2015-12-29 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | YES | ||||||||
| Status | Active | ||||||||
| Mailing Address | 405 E EXCELSIOR AVE VINITA, OK 74301-4226 United States Phone: 918-256-6476 | Fax:918-256-3628 | ||||||||
| Primary Practice Address | 405 E EXCELSIOR AVE VINITA, OK 74301-4226 United States Phone: 918-256-6476 | Fax:918-256-3628 | ||||||||
| Secondary Practice Address(es) | 1805 N YORK ST | ||||||||
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