Provider Demographics
NPI:1568507275
Name:GROVE, ALICIA R (OD)
Entity Type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:R
Last Name:GROVE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:2510 COUNTRYSIDE EASTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-3189
Mailing Address - Country:US
Mailing Address - Phone:317-512-1176
Mailing Address - Fax:
Practice Address - Street 1:106 W BOGGSTOWN RD
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-9706
Practice Address - Country:US
Practice Address - Phone:317-398-9793
Practice Address - Fax:317-392-3444
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2011-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003126152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U90558Medicare UPIN
266610IMedicare PIN