Basic Information
| Provider Information | |||||||||
| NPI: | 1578974952 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | BLOOMER | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7551 9TH ST N STE 100 | ||||||||
| Address2: | |||||||||
| City: | OAKDALE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551286628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517484338 | ||||||||
| FaxNumber: | 6517482892 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 MARKET ST STE 150 | ||||||||
| Address2: | |||||||||
| City: | CHANHASSEN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524914700 | ||||||||
| FaxNumber: | 9524914701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2014 | ||||||||
| LastUpdateDate: | 04/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12658 | WI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 9633 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.