Provider Demographics
NPI:1962581660
Name:GROOMS, DALE FORREST (ATC)
Entity type:Individual
Prefix:MR
First Name:DALE
Middle Name:FORREST
Last Name:GROOMS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 WINNETKA AVE
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:IL
Mailing Address - Zip Code:60093-4238
Mailing Address - Country:US
Mailing Address - Phone:847-501-6445
Mailing Address - Fax:847-446-8247
Practice Address - Street 1:385 WINNETKA AVE
Practice Address - Street 2:
Practice Address - City:WINNETKA
Practice Address - State:IL
Practice Address - Zip Code:60093-4238
Practice Address - Country:US
Practice Address - Phone:847-501-6445
Practice Address - Fax:847-446-8247
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL96000739390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program