Provider Demographics
NPI:1669836797
Name:GRIMES, RAIQUO
Entity Type:Individual
Prefix:
First Name:RAIQUO
Middle Name:
Last Name:GRIMES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7700 NE GREENWOOD DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6798
Mailing Address - Country:US
Mailing Address - Phone:360-573-1933
Mailing Address - Fax:
Practice Address - Street 1:7700 NE GREENWOOD DR
Practice Address - Street 2:SUITE 120
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6798
Practice Address - Country:US
Practice Address - Phone:360-573-1933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60417442225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist