Provider Demographics
NPI:1851869481
Name:GRIMES, JUSTEN JON
Entity Type:Individual
Prefix:
First Name:JUSTEN
Middle Name:JON
Last Name:GRIMES
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 1:3626 MERCUR HILL RD
Mailing Address - Street 2:
Mailing Address - City:WYSOX
Mailing Address - State:PA
Mailing Address - Zip Code:18854-7905
Mailing Address - Country:US
Mailing Address - Phone:570-265-9190
Mailing Address - Fax:
Practice Address - Street 1:401 N FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:LOCK HAVEN
Practice Address - State:PA
Practice Address - Zip Code:17745-2390
Practice Address - Country:US
Practice Address - Phone:570-637-4244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer