Provider Demographics
NPI:1114400702
Name:BLOOMER, KIM
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:BLOOMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6835 FORESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-7988
Mailing Address - Country:US
Mailing Address - Phone:716-930-4422
Mailing Address - Fax:
Practice Address - Street 1:40 LA RIVIERE DR
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-4344
Practice Address - Country:US
Practice Address - Phone:716-893-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005364-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY005364-1OtherNEW YORK STATE