1790851293 NPI number — GROOM ENTERPRISES

Table of content: (NPI 1790851293)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790851293 NPI number — GROOM ENTERPRISES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GROOM ENTERPRISES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NEWPORT AMBULANCE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790851293
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 298
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWPORT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99156-0298
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-447-4108
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
117 S WASHINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWPORT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99156-9665
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-447-4108
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GROOM
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
509-447-4108

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  26X02 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00393077 . This is a "WASHINGTON L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 00001004260 . This is a "BLUE SHIELD IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 804257500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9120502 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: BMKM0 . This is a "BLUE CROSS IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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