Provider Demographics
NPI:1821076282
Name:BLOOM OPTICAL, LLC
Entity Type:Organization
Organization Name:BLOOM OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:D
Authorized Official - Last Name:ALCORN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:402-721-8823
Mailing Address - Street 1:2921 N CLARKSON ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68025-2371
Mailing Address - Country:US
Mailing Address - Phone:402-721-8823
Mailing Address - Fax:402-721-2482
Practice Address - Street 1:2921 N CLARKSON ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-2371
Practice Address - Country:US
Practice Address - Phone:402-721-8823
Practice Address - Fax:402-721-2482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-05
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1085152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10024947900Medicaid
NE4685060001Medicare NSC
NE099310Medicare ID - Type Unspecified