Healthcare Provider Details

I. General information

NPI: 1285122697
Provider Name (Legal Business Name): KEVIN BLOOMFIELD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2018
Last Update Date: 05/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

178 PRIVATE ROAD 19423
SOUTH POINT OH
45680-8831
US

IV. Provider business mailing address

178 PRIVATE ROAD 19423
SOUTH POINT OH
45680-8831
US

V. Phone/Fax

Practice location:
  • Phone: 740-451-0741
  • Fax: 740-313-0426
Mailing address:
  • Phone: 740-451-0741
  • Fax: 740-313-0426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: