Provider Demographics
NPI:1013594308
Name:GRIMES, NICKOLAS PETER (DPM)
Entity type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:PETER
Last Name:GRIMES
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 DAISY ST
Mailing Address - Street 2:
Mailing Address - City:LADERA RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92694-0709
Mailing Address - Country:US
Mailing Address - Phone:949-291-6369
Mailing Address - Fax:949-388-8448
Practice Address - Street 1:310 S HALCYON RD
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-3872
Practice Address - Country:US
Practice Address - Phone:510-917-2334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE6064213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery