Basic Information
| Provider Information | |||||||||
| NPI: | 1114400702 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLOOMER | ||||||||
| FirstName: | KIM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6835 FORESTVIEW DR | ||||||||
| Address2: | |||||||||
| City: | LOCKPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140947988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7169304422 | ||||||||
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| Practice Location | |||||||||
| Address1: | 40 LA RIVIERE DR | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142024344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168931010 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2018 | ||||||||
| LastUpdateDate: | 09/11/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 005364-1 | NY | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 005364-1 | 01 | NY | NEW YORK STATE | OTHER |