Provider Demographics
NPI:1710218904
Name:STEPHEN J. GROTH,MD,INC
Entity Type:Organization
Organization Name:STEPHEN J. GROTH,MD,INC
Other - Org Name:TRIAD TREATMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-545-6930
Mailing Address - Street 1:32272 CAMINO CAPISTRANO
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-3742
Mailing Address - Country:US
Mailing Address - Phone:949-545-6930
Mailing Address - Fax:949-545-6931
Practice Address - Street 1:32272 CAMINO CAPISTRANO
Practice Address - Street 2:SUITE A
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-3742
Practice Address - Country:US
Practice Address - Phone:949-545-6930
Practice Address - Fax:949-545-6931
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STEPHEN J GROTH,MD,INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-27
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36991261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center