Provider Demographics
NPI:1639215007
Name:GRIMM, PAUL VINCENT (DC)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:VINCENT
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 1:110 N TROPICAL TRL
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4737
Mailing Address - Country:US
Mailing Address - Phone:321-459-9400
Mailing Address - Fax:321-459-9422
Practice Address - Street 1:110 N TROPICAL TRL
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4737
Practice Address - Country:US
Practice Address - Phone:321-459-9400
Practice Address - Fax:321-459-9422
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 8328111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV00179Medicare UPIN
FL89253ZMedicare ID - Type Unspecified