Provider Demographics
NPI:1174223002
Name:BLOOM PHYSICAL THERAPY & WELLNESS PLLC
Entity type:Organization
Organization Name:BLOOM PHYSICAL THERAPY & WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER & PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CODY
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:580-967-1355
Mailing Address - Street 1:168579 N 2830 RD
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533-9039
Mailing Address - Country:US
Mailing Address - Phone:580-512-0684
Mailing Address - Fax:
Practice Address - Street 1:4086 COUNTRY CLUB RD STE 2
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-5580
Practice Address - Country:US
Practice Address - Phone:809-671-3555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy