Healthcare Provider Details

I. General information

NPI: 1700920477
Provider Name (Legal Business Name): NORMAN A CROOM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12625 HESPERIA RD
VICTORVILLE CA
92395
US

IV. Provider business mailing address

2661 CINCINNATI ST
SAN BERNARDINO CA
92407
US

V. Phone/Fax

Practice location:
  • Phone: 760-243-1176
  • Fax: 760-955-2356
Mailing address:
  • Phone: 760-955-1777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number00339
License Number StateCA

VIII. Authorized Official

Name: MR. NORMAN ARTHUR CROOM
Title or Position: ALCOHOL DRUG COUNSELOR
Credential: FACT
Phone: 760-243-1176