Provider Demographics
NPI:1053174995
Name:BLOOM GILBERT, CHARMONIX (SUDP-T)
Entity type:Individual
Prefix:
First Name:CHARMONIX
Middle Name:
Last Name:BLOOM GILBERT
Suffix:
Gender:F
Credentials:SUDP-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10157
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99209-1157
Mailing Address - Country:US
Mailing Address - Phone:509-503-6010
Mailing Address - Fax:
Practice Address - Street 1:1302 W GARDNER AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2059
Practice Address - Country:US
Practice Address - Phone:509-503-6010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61493843390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program