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General NPI Number Information
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NPI Number | 1154201044
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Entity Type | Individual
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Provider Name | JUSTIN GROOMS
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Gender | Male
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Dates
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Enumeration Date | 09/03/2025
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Last Update Date | 09/03/2025
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Provider Practice Location Address
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Address Line | 413 N DONNIVAN ST
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City | PRINCETON
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State | KY
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Zip | 42445-1311
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Country | US
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Telephone | 657-217-4006
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Fax |
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Provider Business Mailing Address
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Address Line | 6100 DE SOTO AVE APT 1235
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City | WOODLAND HILLS
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State | CA
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Zip | 91367-3784
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Country | US
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Telephone | 657-217-4006
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251G00000X
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Taxonomy Name | Community Based Hospice Care Agency
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License Number |
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 374U00000X
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Taxonomy Name | Home Health Aide
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License Number |
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License Number State | KY
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