Healthcare Provider Details

I. General information

NPI: 1538922547
Provider Name (Legal Business Name): BENJAMIN DALE GROVE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2024
Last Update Date: 05/20/2024
Certification Date: 05/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 MOCKSVILLE AVE
SALISBURY NC
28144-2732
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-637-1779
  • Fax: 704-637-1121
Mailing address:
  • Phone: 704-637-1779
  • Fax: 704-637-1121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-14202
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: