Healthcare Provider Details

I. General information

NPI: 1427188242
Provider Name (Legal Business Name): DAVID GROOM BC-HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 11/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8568 DEL WEBB BLVD
LAS VEGAS NV
89134
US

IV. Provider business mailing address

8586 DEL WEBB BLVD
LAS VEGAS NV
89134
US

V. Phone/Fax

Practice location:
  • Phone: 702-557-1203
  • Fax:
Mailing address:
  • Phone: 702-557-1203
  • Fax: 503-233-2889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHAS-P-1010102
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: