Provider Demographics
NPI:1952810574
Name:BLOOM, TREVOR LEE
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:LEE
Last Name:BLOOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6645 DEER RD SE
Mailing Address - Street 2:
Mailing Address - City:DENNISON
Mailing Address - State:OH
Mailing Address - Zip Code:44621-9363
Mailing Address - Country:US
Mailing Address - Phone:330-401-4952
Mailing Address - Fax:
Practice Address - Street 1:1972 CLARK AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-3929
Practice Address - Country:US
Practice Address - Phone:800-992-6682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-26
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program