Provider Demographics
NPI:1255369013
Name:GRIMM, ROGER D (ATC)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:D
Last Name:GRIMM
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1470 E. STATE ST.
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47320
Mailing Address - Country:US
Mailing Address - Phone:765-789-6178
Mailing Address - Fax:
Practice Address - Street 1:3813 S. MADISON ST.
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47302
Practice Address - Country:US
Practice Address - Phone:765-751-3362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000488A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer