Provider Demographics
NPI:1316112428
Name:BLOM, GRAYSON (DC)
Entity type:Individual
Prefix:
First Name:GRAYSON
Middle Name:
Last Name:BLOM
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 1:4869 W MALAD ST
Mailing Address - Street 2:STE D
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-8844
Mailing Address - Country:US
Mailing Address - Phone:208-559-0541
Mailing Address - Fax:
Practice Address - Street 1:5975 W. OVERLAND RD.
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709
Practice Address - Country:US
Practice Address - Phone:208-559-0541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1297111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor