MEDICARE: MR. LONNIE N BLOOM PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT00007498	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154322394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LONNIE N BLOOM PT

Provider Business Mailing Address
First Line	:	110 N LAVENTURE RD
Second Line	:	STE A
City	:	MOUNT VERNON
State	:	WA
Zip	:	98273-3901
Country	:	US
Telephone Number	:	360-428-2700
Fax Number	:	360-428-2701

Provider Business Practice Location Address
First Line	:	110 N LAVENTURE RD
Second Line	:	STE A
City	:	MOUNT VERNON
State	:	WA
Zip	:	98273-3901
Country	:	US
Telephone Number	:	360-428-2700
Fax Number	:	360-428-2701

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	04/23/2008

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Directions to “ MR. LONNIE N BLOOM PT” Practice Location

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