Provider Demographics
NPI:1073738712
Name:GROVES, SHERIDON HALE
Entity Type:Individual
Prefix:DR
First Name:SHERIDON
Middle Name:HALE
Last Name:GROVES
Suffix:
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 1:2275 W 25TH ST
Mailing Address - Street 2:#47
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-4901
Mailing Address - Country:US
Mailing Address - Phone:310-521-8651
Mailing Address - Fax:310-521-8651
Practice Address - Street 1:1401 N TUSTIN AVE
Practice Address - Street 2:#140
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-8644
Practice Address - Country:US
Practice Address - Phone:714-543-2554
Practice Address - Fax:714-835-1383
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG68029207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery