Provider Demographics
NPI:1619059060
Name:BRANDON GRIMM D.C. P.A.
Entity Type:Organization
Organization Name:BRANDON GRIMM D.C. P.A.
Other - Org Name:CANYON CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:W
Authorized Official - Last Name:GRIMM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:830-907-3811
Mailing Address - Street 1:14812 SOUTH ACCESS ROAD
Mailing Address - Street 2:
Mailing Address - City:CANYON LAKE
Mailing Address - State:TX
Mailing Address - Zip Code:78133
Mailing Address - Country:US
Mailing Address - Phone:830-907-3811
Mailing Address - Fax:830-907-3812
Practice Address - Street 1:14812 SOUTH ACCESS ROAD
Practice Address - Street 2:
Practice Address - City:CANYON LAKE
Practice Address - State:TX
Practice Address - Zip Code:78133
Practice Address - Country:US
Practice Address - Phone:830-907-3811
Practice Address - Fax:830-907-3812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9268111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1033146170OtherINDIVIDUAL NPI #
TX8U9450OtherBLUE CROSS BLUE SHIELD
TXV00471Medicare UPIN
TX8U9450OtherBLUE CROSS BLUE SHIELD