Provider Demographics
NPI:1851501860
Name:ROBERT ALLEN GROTH
Entity Type:Organization
Organization Name:ROBERT ALLEN GROTH
Other - Org Name:ROBERT GROTH AND ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:GROTH
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:310-987-4478
Mailing Address - Street 1:1840 S GAFFEY ST
Mailing Address - Street 2:SUITE 239
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-5324
Mailing Address - Country:US
Mailing Address - Phone:310-833-8356
Mailing Address - Fax:
Practice Address - Street 1:921 S BEACON ST
Practice Address - Street 2:FLOOR 2
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731
Practice Address - Country:US
Practice Address - Phone:131-083-3835
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16805Medicare ID - Type Unspecified