Basic Information
| Provider Information | |||||||||
| NPI: | 1003359225 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLOOM PHYSICAL THERAPY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3035 S ELLSWORTH RD STE 128 | ||||||||
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| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852122161 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3035 S ELLSWORTH RD STE 128 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852122161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803576500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2016 | ||||||||
| LastUpdateDate: | 11/19/2016 | ||||||||
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| AuthorizedOfficialLastName: | BLOOM | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8082245802 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 8969 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.