Provider Demographics
NPI:1457725285
Name:GRIMES, SAMANTHA (DC)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:
Last Name:GRIMES
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W502 SPUR LN
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN CITY
Mailing Address - State:WI
Mailing Address - Zip Code:54629-7208
Mailing Address - Country:US
Mailing Address - Phone:608-687-1255
Mailing Address - Fax:608-687-1255
Practice Address - Street 1:W502 SPUR LN
Practice Address - Street 2:
Practice Address - City:FOUNTAIN CITY
Practice Address - State:WI
Practice Address - Zip Code:54629-7208
Practice Address - Country:US
Practice Address - Phone:608-687-1255
Practice Address - Fax:608-687-1255
Is Sole Proprietor?:No
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5136-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor