Provider Demographics
NPI:1386739068
Name:GROVA, MANUEL ANGEL
Entity type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:ANGEL
Last Name:GROVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1558 W 68TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-3810
Mailing Address - Country:US
Mailing Address - Phone:305-556-1308
Mailing Address - Fax:
Practice Address - Street 1:1558 W 68TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-3810
Practice Address - Country:US
Practice Address - Phone:305-556-1308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO5339156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician