Healthcare Provider Details

I. General information

NPI: 1265460877
Provider Name (Legal Business Name): MACK JAY GROVES IV DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JAY GROVES IV DPM

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 06/30/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 S TYLER ST
COVINGTON LA
70433-3037
US

IV. Provider business mailing address

323 S STREET
COVINGTON LA
70433-2352
US

V. Phone/Fax

Practice location:
  • Phone: 985-867-9605
  • Fax: 985-867-9001
Mailing address:
  • Phone: 985-867-9605
  • Fax: 985-867-9001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPD190R
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPD190R
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberDPM.190R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: