1467474924 NPI number — MR. STEWART RICHARD BLOOM M.S.W.

Table of content: MR. STEWART RICHARD BLOOM M.S.W. (NPI 1467474924)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467474924 NPI number — MR. STEWART RICHARD BLOOM M.S.W.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLOOM
Provider First Name:
STEWART
Provider Middle Name:
RICHARD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.S.W.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467474924
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6204 JEFJEN WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELK GROVE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95757-5992
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-479-5047
Provider Business Mailing Address Fax Number:
916-973-1047

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3650A AUBURN BOULEVARD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-479-5047
Provider Business Practice Location Address Fax Number:
916-973-1047
Provider Enumeration Date:
07/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LCS 14645 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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