Provider Demographics
NPI:1588219893
Name:KIM M. BLOOMER, RD, CDN
Entity Type:Organization
Organization Name:KIM M. BLOOMER, RD, CDN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:M
Authorized Official - Last Name:BLOOMER
Authorized Official - Suffix:
Authorized Official - Credentials:RD, CDN
Authorized Official - Phone:716-930-4422
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 1:6334 ROBINSON RD
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-7977
Practice Address - Country:US
Practice Address - Phone:716-930-4422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-04
Last Update Date:2019-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty