Provider Demographics
NPI:1255633061
Name:BECKY GRIMM DC SC
Entity type:Organization
Organization Name:BECKY GRIMM DC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER - OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GRIMM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-222-4363
Mailing Address - Street 1:521 S 24TH ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-5730
Mailing Address - Country:US
Mailing Address - Phone:217-222-4363
Mailing Address - Fax:217-222-8027
Practice Address - Street 1:521 S 24TH ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-5730
Practice Address - Country:US
Practice Address - Phone:217-222-4363
Practice Address - Fax:217-222-8027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-30
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-005981111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL772970Medicare PIN