Provider Demographics
NPI:1851701700
Name:NICOLE GROVE LLC
Entity Type:Organization
Organization Name:NICOLE GROVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GROVE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:937-573-7452
Mailing Address - Street 1:102 MARGARETS RUN CT
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:OH
Mailing Address - Zip Code:45322-8743
Mailing Address - Country:US
Mailing Address - Phone:937-573-7452
Mailing Address - Fax:937-540-9553
Practice Address - Street 1:102 MARGARETS RUN CT
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:OH
Practice Address - Zip Code:45322-8743
Practice Address - Country:US
Practice Address - Phone:937-573-7452
Practice Address - Fax:937-540-9553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-30
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0105016Medicaid
OH0105016Medicaid