Provider Demographics
NPI:1679163950
Name:BLOOM, ZACHARY (DC)
Entity Type:Individual
Prefix:DR
First Name:ZACHARY
Middle Name:
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 1:60 NW SHERIDAN RD STE 5
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-6338
Mailing Address - Country:US
Mailing Address - Phone:580-354-9009
Mailing Address - Fax:
Practice Address - Street 1:60 NW SHERIDAN RD STE 5
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6338
Practice Address - Country:US
Practice Address - Phone:580-354-9009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4386111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor