Healthcare Provider Details

I. General information

NPI: 1538051974
Provider Name (Legal Business Name): DEREK LEE GROVES RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2025
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 MILLCREEK DR
HENDERSON KY
42420-5323
US

IV. Provider business mailing address

1050 MILLCREEK DR
HENDERSON KY
42420
US

V. Phone/Fax

Practice location:
  • Phone: 812-475-9712
  • Fax:
Mailing address:
  • Phone: 270-454-4914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number28264125A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: