Provider Demographics
NPI:1306433792
Name:BLOOM, ANNIE
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 SPRING VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:DIVIDE
Mailing Address - State:CO
Mailing Address - Zip Code:80814-9619
Mailing Address - Country:US
Mailing Address - Phone:605-430-5217
Mailing Address - Fax:
Practice Address - Street 1:1836 W KANSAS CITY ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-2516
Practice Address - Country:US
Practice Address - Phone:605-430-5217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-31
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist