Basic Information
| Provider Information | |||||||||
| NPI: | 1477636447 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GROOMS | ||||||||
| FirstName: | MARTY | ||||||||
| MiddleName: | WADE | ||||||||
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| Credential: | OTR L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1122 CRAZY DOE RD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383514718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316935571 | ||||||||
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| Practice Location | |||||||||
| Address1: | 24 PHYSICIANS DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383052070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314102357 | ||||||||
| FaxNumber: | 7314102304 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 10/13/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 02904 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.