Healthcare Provider Details

I. General information

NPI: 1992611495
Provider Name (Legal Business Name): COLLIN VAUGHN GROVER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 JONATHAN LUCAS ST
CHARLESTON SC
29425-8900
US

IV. Provider business mailing address

735 VINE DR
HOLTS SUMMIT MO
65043-4401
US

V. Phone/Fax

Practice location:
  • Phone: 435-230-5773
  • Fax:
Mailing address:
  • Phone: 435-230-5773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: