Healthcare Provider Details

I. General information

NPI: 1851795009
Provider Name (Legal Business Name): DANIELLE JO GROVES RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 10/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 S 16TH ST #1071
CLARINDA IA
51632
US

IV. Provider business mailing address

201 MAIN ST
FONTANELLE IA
50846
US

V. Phone/Fax

Practice location:
  • Phone: 712-542-5142
  • Fax:
Mailing address:
  • Phone: 641-745-5186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number075262
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: