Healthcare Provider Details

I. General information

NPI: 1265565691
Provider Name (Legal Business Name): DEKALB PHYSICIANS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 S RUNNELS ST
DE KALB TX
75559-2317
US

IV. Provider business mailing address

216 N CENTRE ST
DE KALB TX
75559-1406
US

V. Phone/Fax

Practice location:
  • Phone: 903-667-2273
  • Fax: 903-667-7597
Mailing address:
  • Phone: 903-667-2273
  • Fax: 903-667-7597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberL5749
License Number StateTX

VIII. Authorized Official

Name: DR. KYLE WAYNE GROOM
Title or Position: OWNER - PHYSICIAN
Credential: DO
Phone: 903-667-2273