MEDICARE: MR. MANUEL ANGEL GROVA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician	DO5339	FL

General Provider Information

NPI Number	:	1386739068
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MANUEL ANGEL GROVA

Provider Business Mailing Address
First Line	:	1558 W 68TH ST
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33014-3810
Country	:	US
Telephone Number	:	305-556-1308
Fax Number	:

Provider Business Practice Location Address
First Line	:	1558 W 68TH ST
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33014-3810
Country	:	US
Telephone Number	:	305-556-1308
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	07/08/2007

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Directions to “ MR. MANUEL ANGEL GROVA ” Practice Location

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