Provider Demographics
NPI:1982187209
Name:GRIMM, KELLEN (L AC)
Entity Type:Individual
Prefix:
First Name:KELLEN
Middle Name:
Last Name:GRIMM
Suffix:
Gender:M
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 S WATER ST STE 200
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-1668
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:531 S WATER ST STE 200
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-1668
Practice Address - Country:US
Practice Address - Phone:517-242-1870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-12
Last Update Date:2022-11-16
Deactivation Date:2021-04-01
Deactivation Code:
Reactivation Date:2022-11-16
Provider Licenses
StateLicense IDTaxonomies
WI967-55171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist