Provider Demographics
NPI:1154201044
Name:GROOMS, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:GROOMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 DE SOTO AVE APT 1235
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-3784
Mailing Address - Country:US
Mailing Address - Phone:657-217-4006
Mailing Address - Fax:
Practice Address - Street 1:413 N DONNIVAN ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:KY
Practice Address - Zip Code:42445-1311
Practice Address - Country:US
Practice Address - Phone:657-217-4006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-03
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY251G00000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No251G00000XAgenciesHospice Care, Community Based