Provider Demographics
NPI:1346547916
Name:GROOMS, VAN
Entity Type:Individual
Prefix:
First Name:VAN
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 1:208 W 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4429
Mailing Address - Country:US
Mailing Address - Phone:405-372-0508
Mailing Address - Fax:405-372-0693
Practice Address - Street 1:208 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4429
Practice Address - Country:US
Practice Address - Phone:405-372-0508
Practice Address - Fax:405-372-0693
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-17
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor