Provider Demographics
NPI:1164715504
Name:BLOOM NATURAL HEALTHCARE
Entity Type:Organization
Organization Name:BLOOM NATURAL HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:HAYMAN
Authorized Official - Last Name:O'NEILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-223-2741
Mailing Address - Street 1:125 NE KILLINGSWORTH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-2664
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 NE KILLINGSWORTH ST STE 101
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-2664
Practice Address - Country:US
Practice Address - Phone:503-223-3741
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-18
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01051171100000X
OR1526175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty