Provider Demographics
NPI:1902471071
Name:BLOOM PHYSICAL THERAPY
Entity Type:Organization
Organization Name:BLOOM PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:503-930-5025
Mailing Address - Street 1:5620 CINNAMON TEAL ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-3300
Mailing Address - Country:US
Mailing Address - Phone:503-930-5025
Mailing Address - Fax:
Practice Address - Street 1:2659 COMMERCIAL ST SE STE 282B
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4445
Practice Address - Country:US
Practice Address - Phone:503-930-5025
Practice Address - Fax:503-967-7604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-21
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy