Healthcare Provider Details

I. General information

NPI: 1942114681
Provider Name (Legal Business Name): RAVIN ROSE GROVE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 SMITHVILLE CHURCH RD
WARNER ROBINS GA
31088-7803
US

IV. Provider business mailing address

203 LORAINE WOODS DR
MACON GA
31210-5330
US

V. Phone/Fax

Practice location:
  • Phone: 478-333-3320
  • Fax:
Mailing address:
  • Phone: 865-266-9099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT015939
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: