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General NPI Number Information
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NPI Number | 1265460877
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Entity Type | Individual
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Provider Name | MACK JAY GROVES IV DPM
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Gender | Male
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Dates
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Enumeration Date | 06/30/2006
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Last Update Date | 06/30/2025
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Provider Practice Location Address
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Address Line | 323 S TYLER ST
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City | COVINGTON
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State | LA
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Zip | 70433-3037
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Country | US
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Telephone | 985-867-9605
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Fax | 985-867-9001
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Provider Business Mailing Address
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Address Line | 323 S STREET
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City | COVINGTON
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State | LA
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Zip | 70433-2352
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Country | US
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Telephone | 985-867-9605
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Fax | 985-867-9001
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | PD190R
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 213ES0131X
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Taxonomy Name | Foot Surgery Podiatrist
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License Number | PD190R
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License Number State | LA
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Taxonomy #3
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Taxonomy Code | 213EP1101X
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Taxonomy Name | Primary Podiatric Medicine Podiatrist
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License Number | DPM.190R
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License Number State | LA
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