Provider Demographics
NPI:1033725460
Name:GRIMES, ERIC A
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:A
Last Name:GRIMES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 DOLPHIN CIR E
Mailing Address - Street 2:
Mailing Address - City:BAYVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08721-2461
Mailing Address - Country:US
Mailing Address - Phone:732-779-5087
Mailing Address - Fax:
Practice Address - Street 1:72 DOLPHIN CIR E
Practice Address - Street 2:
Practice Address - City:BAYVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08721-2461
Practice Address - Country:US
Practice Address - Phone:732-779-5087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT01326800225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist