Healthcare Provider Details

I. General information

NPI: 1619986965
Provider Name (Legal Business Name): JASON EDWARD GROOMER D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 01/13/2023
Certification Date: 01/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18531 ROSCOE BLVD STE 215
NORTHRIDGE CA
91324-5975
US

IV. Provider business mailing address

6520 PLATT AVENUE # 827
WEST HILLS CA
91307
US

V. Phone/Fax

Practice location:
  • Phone: 818-700-0411
  • Fax:
Mailing address:
  • Phone: 818-825-7174
  • Fax: 818-579-9233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number20A8134
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A8134
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: