Provider Demographics
NPI:1013225184
Name:GROVE, CRYSTAL ELAINE
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:ELAINE
Last Name:GROVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1149 HAZEL DELL RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62246-3002
Mailing Address - Country:US
Mailing Address - Phone:618-335-1624
Mailing Address - Fax:
Practice Address - Street 1:1149 HAZEL DELL RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-3002
Practice Address - Country:US
Practice Address - Phone:618-335-1624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter