Provider Demographics
NPI:1053493999
Name:BLOOMINGDALE, STEPHEN ALLEN (DC)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ALLEN
Last Name:BLOOMINGDALE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:TOCCOA
Mailing Address - State:GA
Mailing Address - Zip Code:30577-8432
Mailing Address - Country:US
Mailing Address - Phone:706-827-9941
Mailing Address - Fax:
Practice Address - Street 1:92 BETTY'S CREEK ROAD
Practice Address - Street 2:
Practice Address - City:DILLARD
Practice Address - State:GA
Practice Address - Zip Code:30537
Practice Address - Country:US
Practice Address - Phone:706-782-7878
Practice Address - Fax:706-746-5643
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2262111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician