Provider Demographics
NPI:1750454021
Name:GRIM, LEO CHARLES (DC)
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:CHARLES
Last Name:GRIM
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 1:1406 VERMONT ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77006-1040
Mailing Address - Country:US
Mailing Address - Phone:713-522-6336
Mailing Address - Fax:713-522-8372
Practice Address - Street 1:1406 VERMONT ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77006-1040
Practice Address - Country:US
Practice Address - Phone:713-522-6336
Practice Address - Fax:713-522-8372
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6546111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU61029Medicare UPIN