Provider Demographics
NPI:1194151191
Name:GROOVER, SHANNON GEORGE
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:GEORGE
Last Name:GROOVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 SENATORS RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-1256
Mailing Address - Country:US
Mailing Address - Phone:770-505-3333
Mailing Address - Fax:678-809-0467
Practice Address - Street 1:346 SENATORS RIDGE DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132-1256
Practice Address - Country:US
Practice Address - Phone:770-505-3333
Practice Address - Fax:678-809-0467
Is Sole Proprietor?:No
Enumeration Date:2013-09-23
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA646315171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor