Provider Demographics
NPI:1346712056
Name:BLOOM HEALTH AND WELLNESS PROMOTION
Entity Type:Organization
Organization Name:BLOOM HEALTH AND WELLNESS PROMOTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAHLSTROM-NOPP
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, LD
Authorized Official - Phone:541-337-3437
Mailing Address - Street 1:PO BOX 7794
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97475-0030
Mailing Address - Country:US
Mailing Address - Phone:541-337-3437
Mailing Address - Fax:541-833-0675
Practice Address - Street 1:296 E 5TH AVE STE 321
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2771
Practice Address - Country:US
Practice Address - Phone:541-337-3437
Practice Address - Fax:541-833-0675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty