Provider Demographics
NPI:1114301843
Name:BLOM, JACOBUS
Entity Type:Individual
Prefix:
First Name:JACOBUS
Middle Name:
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 1:40 GRANITE HILL RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:ME
Mailing Address - Zip Code:04351-3513
Mailing Address - Country:US
Mailing Address - Phone:207-626-7222
Mailing Address - Fax:
Practice Address - Street 1:40 GRANITE HILL RD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:ME
Practice Address - Zip Code:04351-3513
Practice Address - Country:US
Practice Address - Phone:207-626-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2764225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist