Provider Demographics
NPI:1730812538
Name:BLOOM MEDICAL AND AESTHETICS
Entity type:Organization
Organization Name:BLOOM MEDICAL AND AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHNIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BLUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-424-9739
Mailing Address - Street 1:8340 SANGRE DE CRISTO RD STE 202
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80127-4252
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8340 SANGRE DE CRISTO RD STE 202
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80127-4252
Practice Address - Country:US
Practice Address - Phone:970-424-9793
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty