Provider Demographics
NPI:1073781589
Name:GRIMES, CLINTON LLOYD (BS)
Entity Type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:LLOYD
Last Name:GRIMES
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NBU 6907
Mailing Address - Street 2:
Mailing Address - City:PRAGUE
Mailing Address - State:OK
Mailing Address - Zip Code:74864
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:369026 US HIGHWAY 62
Practice Address - Street 2:
Practice Address - City:BOLEY
Practice Address - State:OK
Practice Address - Zip Code:74829
Practice Address - Country:US
Practice Address - Phone:918-667-3367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-19
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100685660AMedicaid
OK100685660DMedicaid