Provider Demographics
NPI:1659944916
Name:BLOOM CHIROPRACTIC & WELLNESS, LLC
Entity Type:Organization
Organization Name:BLOOM CHIROPRACTIC & WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SYDNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:470-604-6817
Mailing Address - Street 1:1290 KENNESTONE CIR STE 211
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-6009
Mailing Address - Country:US
Mailing Address - Phone:470-604-6817
Mailing Address - Fax:
Practice Address - Street 1:1290 KENNESTONE CIR STE 211
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-6009
Practice Address - Country:US
Practice Address - Phone:470-604-6817
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty