Provider Demographics
NPI:1790587160
Name:GRIMM, CORY RAYMOND
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:RAYMOND
Last Name:GRIMM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5669 TARAWA BLVD
Mailing Address - Street 2:
Mailing Address - City:TARAWA TERRACE
Mailing Address - State:NC
Mailing Address - Zip Code:28543-1325
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5669 TARAWA BLVD
Practice Address - Street 2:
Practice Address - City:TARAWA TERRACE
Practice Address - State:NC
Practice Address - Zip Code:28543-1325
Practice Address - Country:US
Practice Address - Phone:470-334-8279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-26
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other