Provider Demographics
NPI:1104013119
Name:GRIMM, DANIEL PAUL (DC)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:PAUL
Last Name:GRIMM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 S TAYLOR DR
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-4766
Mailing Address - Country:US
Mailing Address - Phone:920-451-7000
Mailing Address - Fax:920-451-7100
Practice Address - Street 1:909 S TAYLOR DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-4766
Practice Address - Country:US
Practice Address - Phone:920-451-7000
Practice Address - Fax:920-451-7100
Is Sole Proprietor?:No
Enumeration Date:2007-10-03
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4491-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000035542OtherMEDICARE GROUP ID
WI355420004Medicare PIN