Healthcare Provider Details

I. General information

NPI: 1043131493
Provider Name (Legal Business Name): LINNAEUS BLOOM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: LEE BLOOM

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 SW SKYLINE BLVD STE 109
PORTLAND OR
97221-2547
US

IV. Provider business mailing address

4611 NE 33RD AVE
PORTLAND OR
97211-7055
US

V. Phone/Fax

Practice location:
  • Phone: 971-293-2326
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: