Provider Demographics
NPI:1457558751
Name:GROVES, LARRY WAYNE (PT, ATC)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:WAYNE
Last Name:GROVES
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 BLUE JAY ST
Mailing Address - Street 2:
Mailing Address - City:BURKBURNETT
Mailing Address - State:TX
Mailing Address - Zip Code:76354-2859
Mailing Address - Country:US
Mailing Address - Phone:940-569-1095
Mailing Address - Fax:
Practice Address - Street 1:149 HART ST
Practice Address - Street 2:82D MEDICAL GROUP - SGH
Practice Address - City:SHEPPARD AFB
Practice Address - State:TX
Practice Address - Zip Code:76311-3477
Practice Address - Country:US
Practice Address - Phone:940-676-4274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPT01648171000000X
MOAT00007171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD 000Medicare UPIN