Healthcare Provider Details

I. General information

NPI: 1841934866
Provider Name (Legal Business Name): BLOOM IDAHO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2022
Last Update Date: 01/04/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10965 W OVERLAND ROAD
BOISE ID
83709
US

IV. Provider business mailing address

PO BOX 5943
VIRGINIA BEACH VA
23471-0943
US

V. Phone/Fax

Practice location:
  • Phone: 208-900-9901
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SPENCER SMITH
Title or Position: CEO
Credential:
Phone: 208-853-3000