Provider Demographics
NPI:1114428117
Name:BLOOM CHIROPRACTIC AND WELLNESS PLLC
Entity Type:Organization
Organization Name:BLOOM CHIROPRACTIC AND WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:814-791-0213
Mailing Address - Street 1:407 THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:CURWENSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16833-1115
Mailing Address - Country:US
Mailing Address - Phone:814-791-0213
Mailing Address - Fax:
Practice Address - Street 1:407 THOMPSON ST
Practice Address - Street 2:
Practice Address - City:CURWENSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16833-1115
Practice Address - Country:US
Practice Address - Phone:814-791-0213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-24
Last Update Date:2018-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC011292111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1033637920001Medicaid