Provider Demographics
NPI:1154705119
Name:GROOMS, JOHNNY ALLEN
Entity type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:ALLEN
Last Name:GROOMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 CLOVERDALE ST
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-5894
Mailing Address - Country:US
Mailing Address - Phone:870-476-9698
Mailing Address - Fax:
Practice Address - Street 1:1808 CLOVERDALE ST
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-5894
Practice Address - Country:US
Practice Address - Phone:870-476-9698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-19
Last Update Date:2015-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAT2842255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer