Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207VX0000X | Obstetrician | H8090 | TX |
NPI | 1083671481 |
---|---|
Provider Name | Clarice Leavon Grimes |
First Address | Dallas, TX 75284-5347 |
Second Address | Dallas, TX 75390-7208 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/04/2006 |
Last Update Date | 05/11/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
138578311 | (05) | TX |
F40067 | (02) |