Provider Demographics
NPI:1235946864
Name:GRIMSLEY, MARCUS S JR
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:S
Last Name:GRIMSLEY
Suffix:JR
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 1:436 COAST GUARD RD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:LA
Mailing Address - Zip Code:70091-4340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:436 COAST GUARD RD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:LA
Practice Address - Zip Code:70091-4340
Practice Address - Country:US
Practice Address - Phone:504-915-7195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman