Provider Demographics
NPI:1548298250
Name:BLOOM, RICHARD R (DC)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:R
Last Name:BLOOM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 OCEANFOREST DR W
Mailing Address - Street 2:13947 BEACH BLVD # 202
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-6612
Mailing Address - Country:US
Mailing Address - Phone:904-223-3000
Mailing Address - Fax:904-223-4560
Practice Address - Street 1:13947 BEACH BLVD STE 202
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-1200
Practice Address - Country:US
Practice Address - Phone:904-223-3330
Practice Address - Fax:904-223-4560
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8853111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU80825Medicare UPIN