Provider Demographics
NPI:1043833494
Name:BLOM, JOSHUA JACOB
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:JACOB
Last Name:BLOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-3645
Mailing Address - Country:US
Mailing Address - Phone:605-664-4220
Mailing Address - Fax:605-664-4221
Practice Address - Street 1:613 WALNUT ST
Practice Address - Street 2:
Practice Address - City:YANKTON
Practice Address - State:SD
Practice Address - Zip Code:57078-3645
Practice Address - Country:US
Practice Address - Phone:605-664-4220
Practice Address - Fax:605-664-4221
Is Sole Proprietor?:No
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator