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General NPI Number Information
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NPI Number | 1053842872
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Entity Type | Organization
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Legal Business Name | BLOOM PEDIATRIC THERAPY
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Dates
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Enumeration Date | 03/23/2017
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Last Update Date | 03/23/2017
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Provider Practice Location Address
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Address Line | 1286 S BARNES DR
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City | BLOOMINGTON
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State | IN
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Zip | 47401-8632
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Country | US
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Telephone | 812-320-8892
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 5443
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City | BLOOMINGTON
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State | IN
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Zip | 47407-5443
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DUSTIN PLUMMER
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Credential |
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Telephone | 812-320-8892
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0400X
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Taxonomy Name | Rehabilitation Clinic/Center
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License Number |
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License Number State | IN
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