MEDICARE: BLOOMFIELD CHIROPRACTOR CENTER INC

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	111N00000X	Chiropractor	5558	CO
2	111N00000X	Chiropractor	782	NM

General Provider Information

NPI Number	:	1891795589
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOOMFIELD CHIROPRACTOR CENTER INC

Provider Business Mailing Address
First Line	:	308 N 1ST ST
Second Line	:
City	:	BLOOMFIELD
State	:	NM
Zip	:	87413-5305
Country	:	US
Telephone Number	:	505-632-1111
Fax Number	:	505-632-1111

Provider Business Practice Location Address
First Line	:	308 N 1ST ST
Second Line	:
City	:	BLOOMFIELD
State	:	NM
Zip	:	87413-5305
Country	:	US
Telephone Number	:	505-632-1111
Fax Number	:	505-632-1111

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROBIN IRVIN GLASS
Credential	:	DC DACNB
Telephone Number	:	505-632-1111

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	08/22/2020

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