=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952310773
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LARRY M. BLOOM OD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2006
-----------------------------------------------------
Last Update Date | 11/19/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5600 MONROE ST STE 102
-----------------------------------------------------
City | SYLVANIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43560-2731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-882-8467
-----------------------------------------------------
Fax | 419-882-8951
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5600 MONROE ST
-----------------------------------------------------
City | SYLVANIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43560-2731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-882-8467
-----------------------------------------------------
Fax | 419-882-8951
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MS. KELLI J SCHULTZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 419-882-8467
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2757/T1242
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------