Provider Demographics
NPI:1184127995
Name:BLOOM CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:BLOOM CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:ISABEL
Authorized Official - Last Name:GIL DE RUBIO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:787-587-5267
Mailing Address - Street 1:6634 MERRYVALE LN
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-4037
Mailing Address - Country:US
Mailing Address - Phone:787-587-5267
Mailing Address - Fax:
Practice Address - Street 1:545 W GRANADA BLVD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5103
Practice Address - Country:US
Practice Address - Phone:386-672-6243
Practice Address - Fax:386-677-7463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-18
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10626111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherSUBMITTING PAPERWORK FOR MEDICARE