Provider Demographics
NPI:1083014732
Name:GRIM, LUCAS
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:
Last Name:GRIM
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 1:220 BREWSTER RD
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:16102-3004
Mailing Address - Country:US
Mailing Address - Phone:724-730-4336
Mailing Address - Fax:
Practice Address - Street 1:1972 CLARK AVE
Practice Address - Street 2:BOX #664
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-3929
Practice Address - Country:US
Practice Address - Phone:724-730-4336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-31
Last Update Date:2014-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer