Provider Demographics
NPI:1720138621
Name:GRIMES, KEVIN THOMAS (BA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:THOMAS
Last Name:GRIMES
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8459
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97207-8459
Mailing Address - Country:US
Mailing Address - Phone:503-238-0769
Mailing Address - Fax:
Practice Address - Street 1:509 NE ALBERTA ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3976
Practice Address - Country:US
Practice Address - Phone:503-249-7767
Practice Address - Fax:503-331-7595
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion