Provider Demographics
NPI:1659365781
Name:GROVE, RYAN S (ATC)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:S
Last Name:GROVE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3483 CRYSTAL LN
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33330-4630
Mailing Address - Country:US
Mailing Address - Phone:412-292-6249
Mailing Address - Fax:
Practice Address - Street 1:7500 SW 30TH ST
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-1020
Practice Address - Country:US
Practice Address - Phone:954-452-7008
Practice Address - Fax:954-452-7069
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-05
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART001346A174400000X
FLAL 3939174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist