Provider Demographics
NPI:1568405140
Name:GROOM, JULIE H (OD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:H
Last Name:GROOM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:30688 BENTON RD
Mailing Address - Street 2:STE B101
Mailing Address - City:WINCHESTER
Mailing Address - State:CA
Mailing Address - Zip Code:92596-8469
Mailing Address - Country:US
Mailing Address - Phone:951-719-1670
Mailing Address - Fax:951-719-1671
Practice Address - Street 1:40945 WINCHESTER RD
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-6031
Practice Address - Country:US
Practice Address - Phone:951-719-1670
Practice Address - Fax:951-719-1671
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAOPT12115152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U80538Medicare UPIN