MEDICARE: BLOOM VISION, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist		PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	436035	OTHER	PA	KEYSTONE HEALTH PLAN CENT
2	436035	OTHER	PA	BLUE SHIELD
3	436035	OTHER	PA	FIRST PRIORITY HEALTH
4	02497000	OTHER	PA	CAPITAL BLUE CROSS

General Provider Information

NPI Number	:	1255339065
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOOM VISION, LLC

Provider Business Mailing Address
First Line	:	301 EAST ST
Second Line	:
City	:	BLOOMSBURG
State	:	PA
Zip	:	17815-1846
Country	:	US
Telephone Number	:	570-387-8800
Fax Number	:	570-784-8887

Provider Business Practice Location Address
First Line	:	301 EAST ST
Second Line	:
City	:	BLOOMSBURG
State	:	PA
Zip	:	17815-1846
Country	:	US
Telephone Number	:	570-387-8800
Fax Number	:	570-784-8887

Authorized Official
Title or Position	:	BILLING CLERK
Name	:	TRACY SAVIDGE
Credential	:
Telephone Number	:	570-387-8800

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	07/21/2022

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Directions to “BLOOM VISION, LLC ” Practice Location

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