Basic Information
| Provider Information | |||||||||
| NPI: | 1255950275 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIMES | ||||||||
| FirstName: | AMIEE | ||||||||
| MiddleName: | MICHELE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | I | ||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RAINES | ||||||||
| OtherFirstName: | AMIEE | ||||||||
| OtherMiddleName: | MICHELE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3647 HIGHWAY 39 | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976032612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418845244 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3647 HIGHWAY 39 | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976032612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418845244 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2020 | ||||||||
| LastUpdateDate: | 04/09/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156F00000X | OR | Y | Eye and Vision Services Providers | Technician/Technologist |
No ID Information.