Provider Demographics
NPI:1144358193
Name:GROOMS, ROBERTA LOVING
Entity type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:LOVING
Last Name:GROOMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 FEDERAL ST
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24504
Mailing Address - Country:US
Mailing Address - Phone:434-845-4403
Mailing Address - Fax:434-846-0491
Practice Address - Street 1:1223 FILLMORE ST
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501
Practice Address - Country:US
Practice Address - Phone:434-528-5245
Practice Address - Fax:434-846-0491
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA102251C00000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251C00000XAgenciesDay Training, Developmentally Disabled Services
Not Answered3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4946472Medicaid