Provider Demographics
NPI:1457579609
Name:GRIMES, JERRY D
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:D
Last Name:GRIMES
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JERRY
Other - Middle Name:D
Other - Last Name:GRIMES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ORT
Mailing Address - Street 1:PO BOX 28094
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30358-0094
Mailing Address - Country:US
Mailing Address - Phone:678-488-5272
Mailing Address - Fax:770-723-9352
Practice Address - Street 1:705 WHISPER TRL
Practice Address - Street 2:APT #204B
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30168-7135
Practice Address - Country:US
Practice Address - Phone:678-488-5272
Practice Address - Fax:770-723-9352
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist