Provider Demographics
NPI:1063806156
Name:BLOOM, ELIZABETH (RDN)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BLOOM
Suffix:
Gender:
Credentials:RDN
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:PIKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN
Mailing Address - Street 1:PO BOX 4251
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81302-4251
Mailing Address - Country:US
Mailing Address - Phone:507-261-3535
Mailing Address - Fax:
Practice Address - Street 1:160 E 12TH ST STE 1
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5261
Practice Address - Country:US
Practice Address - Phone:970-236-8090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-26
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86027442133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered