Provider Demographics
NPI:1871971978
Name:GRIMMER, JAMES JR
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:GRIMMER
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 1:236 WILLOWGROVE S
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-4517
Mailing Address - Country:US
Mailing Address - Phone:716-228-9565
Mailing Address - Fax:
Practice Address - Street 1:1410 PINE AVE
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14301-1922
Practice Address - Country:US
Practice Address - Phone:716-228-9565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005121171100000X
NY021911225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY13551676OtherCAQH