Provider Demographics
NPI:1891795589
Name:BLOOMFIELD CHIROPRACTOR CENTER INC
Entity type:Organization
Organization Name:BLOOMFIELD CHIROPRACTOR CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:IRVIN
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:DC DACNB
Authorized Official - Phone:505-632-1111
Mailing Address - Street 1:308 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413-5305
Mailing Address - Country:US
Mailing Address - Phone:505-632-1111
Mailing Address - Fax:505-632-1111
Practice Address - Street 1:308 N 1ST ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-5305
Practice Address - Country:US
Practice Address - Phone:505-632-1111
Practice Address - Fax:505-632-1111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5558111N00000X
NM782111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
267-2780Medicare ID - Type Unspecified