Individual
ETHAN NATHANIEL GRIMES
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
124 CISCO RD, LEXINGTON, KY 40504-1143
(859) 253-1686
Mailing address
124 CISCO RD, LEXINGTON, KY 40504-1143
(859) 253-1686
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1790731081
—
KY
Enumeration date
02/28/2017
Last updated
03/09/2017
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