Healthcare Provider Details

I. General information

NPI: 1497277594
Provider Name (Legal Business Name): CHELSEA RAE BLOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2017
Last Update Date: 07/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16347 MATEO ST
SAN LEANDRO CA
94578-3129
US

IV. Provider business mailing address

16347 MATEO ST
SAN LEANDRO CA
94578-3129
US

V. Phone/Fax

Practice location:
  • Phone: 510-909-2430
  • Fax:
Mailing address:
  • Phone: 510-909-2430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000029662
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: