Healthcare Provider Details

I. General information

NPI: 1316531106
Provider Name (Legal Business Name): STACY MARIE GROVER CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2021
Last Update Date: 02/23/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

459 PATTERSON RD BLDG 110
HONOLULU HI
96819-1522
US

IV. Provider business mailing address

1824 PUOWAINA DR
HONOLULU HI
96813-1706
US

V. Phone/Fax

Practice location:
  • Phone: 808-430-0090
  • Fax:
Mailing address:
  • Phone: 503-930-7454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: