Provider Demographics
NPI:1114035490
Name:GRIM, CHARLES J (DC)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:GRIM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1924 PARKER AVE
Mailing Address - Street 2:
Mailing Address - City:HOLMES
Mailing Address - State:PA
Mailing Address - Zip Code:19043-1414
Mailing Address - Country:US
Mailing Address - Phone:610-237-6645
Mailing Address - Fax:610-237-6473
Practice Address - Street 1:1924 PARKER AVE
Practice Address - Street 2:
Practice Address - City:HOLMES
Practice Address - State:PA
Practice Address - Zip Code:19043-1414
Practice Address - Country:US
Practice Address - Phone:610-237-6645
Practice Address - Fax:610-237-6473
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC002444L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor