Provider Demographics
NPI:1790851293
Name:GROOM ENTERPRISES
Entity Type:Organization
Organization Name:GROOM ENTERPRISES
Other - Org Name:NEWPORT AMBULANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:GROOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-447-4108
Mailing Address - Street 1:PO BOX 298
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:WA
Mailing Address - Zip Code:99156-0298
Mailing Address - Country:US
Mailing Address - Phone:509-447-4108
Mailing Address - Fax:
Practice Address - Street 1:117 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:WA
Practice Address - Zip Code:99156-9665
Practice Address - Country:US
Practice Address - Phone:509-447-4108
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA26X023416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA00393077OtherWASHINGTON L&I
ID00001004260OtherBLUE SHIELD IDAHO
ID804257500Medicaid
WA9120502Medicaid
IDBMKM0OtherBLUE CROSS IDAHO
WA00393077OtherWASHINGTON L&I
WAG000301100Medicare PIN