Provider Demographics
NPI:1912367202
Name:GRIM, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GRIM
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 1:2277 SUNRISE DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-3751
Mailing Address - Country:US
Mailing Address - Phone:775-287-6029
Mailing Address - Fax:
Practice Address - Street 1:2277 SUNRISE DR
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-3751
Practice Address - Country:US
Practice Address - Phone:775-287-6029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV49194300001Medicaid