Healthcare Provider Details

I. General information

NPI: 1134856875
Provider Name (Legal Business Name): CORBEN BLOOMER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2022
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date: 05/22/2023
Reactivation Date: 06/12/2023

III. Provider practice location address

600 E MOLEN RD
FERRON UT
84523-4503
US

IV. Provider business mailing address

90 E 200 N
LOGAN UT
84321-4034
US

V. Phone/Fax

Practice location:
  • Phone: 435-609-6811
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: