Organization
DEKALB PHYSICIANS CLINIC LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. KYLE WAYNE GROOM DO (OWNER - PHYSICIAN)
(903) 667-2273
Entity
Organization
Contact information
Practice address
1250 S RUNNELS ST, DE KALB, TX 75559-2317
(903) 667-2273
(903) 667-7597
Mailing address
216 N CENTRE ST, DE KALB, TX 75559-1406
(903) 667-2273
(903) 667-7597
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
L5749
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
177214701
—
TX
01
—
8P152
ARK BLUE CROSS BLUE SHIEL
AR
01
—
8S7090
BLUE CROSS BLUE SHIELD
TX
Enumeration date
03/14/2007
Last updated
01/30/2023
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