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General NPI Number Information
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NPI Number | 1407904188
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Entity Type | Individual
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Provider Name | SCOTT BLOOM
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Gender | Male
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Dates
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Enumeration Date | 01/08/2007
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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 | 269-945-3937
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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 | 269-945-2192
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Fax | 269-945-3937
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 4903603
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License Number State | MI
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