MEDICARE: BLOOM IDAHO 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	261QU0200X	Urgent Care Clinic/Center
2	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1679134126
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOOM IDAHO LLC

Provider Business Mailing Address
First Line	:	50 HENRY ST
Second Line	:
City	:	CORTEZ
State	:	CO
Zip	:	81321-3012
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6965 N GLENWOOD ST
Second Line	:
City	:	GARDEN CITY
State	:	ID
Zip	:	83714-1967
Country	:	US
Telephone Number	:	208-853-3000
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	SPENCER SMITH
Credential	:
Telephone Number	:	208-853-3000

Provider Enumeration Date	:	06/25/2019
Last Update Date	:	05/02/2022

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Directions to “BLOOM IDAHO LLC ” Practice Location

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