Healthcare Provider Details

I. General information

NPI: 1780291088
Provider Name (Legal Business Name): BLOOM IDAHO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2020
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 CALDWELL BLVD
NAMPA ID
83651-1728
US

IV. Provider business mailing address

PO BOX 5943
VIRGINIA BEACH VA
23471-0943
US

V. Phone/Fax

Practice location:
  • Phone: 208-207-8500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SPENCER SMITH
Title or Position: CEO
Credential:
Phone: 208-207-8500