Provider Demographics
NPI:1619174174
Name:BLOOM, BRUCE DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:DAVID
Last Name:BLOOM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10603-4032
Mailing Address - Country:US
Mailing Address - Phone:919-949-6009
Mailing Address - Fax:
Practice Address - Street 1:25 LAKE ST
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10603-4032
Practice Address - Country:US
Practice Address - Phone:919-949-6009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX003040-1111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition