Provider Demographics
NPI:1467069658
Name:GRIMM, DWIGHT
Entity Type:Individual
Prefix:MR
First Name:DWIGHT
Middle Name:
Last Name:GRIMM
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 1:912 WAYNOKA DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WAYNOKA
Mailing Address - State:OH
Mailing Address - Zip Code:45171-9760
Mailing Address - Country:US
Mailing Address - Phone:937-446-4149
Mailing Address - Fax:
Practice Address - Street 1:912 WAYNOKA DR
Practice Address - Street 2:
Practice Address - City:LAKE WAYNOKA
Practice Address - State:OH
Practice Address - Zip Code:45171-9760
Practice Address - Country:US
Practice Address - Phone:937-446-4149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2971048Medicaid
OH0800557Medicaid