Provider Demographics
NPI:1750947875
Name:GRIMES, TRAVIS R
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:R
Last Name:GRIMES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2079 TRAILING PINES WAY
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32003-4921
Mailing Address - Country:US
Mailing Address - Phone:904-505-0125
Mailing Address - Fax:
Practice Address - Street 1:2079 TRAILING PINES WAY
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32003-4921
Practice Address - Country:US
Practice Address - Phone:904-505-0125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant