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General NPI Number Information
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NPI Number | 1376732131
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Entity Type | Organization
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Legal Business Name | SCOTT BLOOM OD PLC
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Dates
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Enumeration Date | 10/17/2007
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Last Update Date | 03/10/2009
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Provider Practice Location Address
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Address Line | 1510 N BROADWAY ST
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City | HASTINGS
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State | MI
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Zip | 49058-1007
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Country | US
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Telephone | 269-945-2192
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Fax |
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Provider Business Mailing Address
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Address Line | 1510 N BROADWAY ST
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City | HASTINGS
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State | MI
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Zip | 49058-1007
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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 | OWNER
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Name | SCOTT BLOOM
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Credential | O.D.
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Telephone | 269-945-2192
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 4901003603
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License Number State | MI
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