Provider Demographics
NPI:1427188242
Name:GROOM, DAVID (BC-HIS)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:GROOM
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8586 DEL WEBB BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89134
Mailing Address - Country:US
Mailing Address - Phone:702-557-1203
Mailing Address - Fax:503-233-2889
Practice Address - Street 1:8568 DEL WEBB BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89134
Practice Address - Country:US
Practice Address - Phone:702-557-1203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORHAS-P-1010102237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR212936Medicaid
2432417000OtherFEDERAL WORKERS COMP
2432417000OtherFEDERAL WORKERS COMP