Basic Information
| Provider Information | |||||||||
| NPI: | 1780088609 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLOOM BEHAVIORAL SOLUTIONS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BLOOM REHABILITATIVE SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9141 CYPRESS GREEN DR STE 2 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322562006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046471849 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9141 CYPRESS GREEN DR STE 2 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322562006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046471849 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2014 | ||||||||
| LastUpdateDate: | 10/21/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COVINGTON | ||||||||
| AuthorizedOfficialFirstName: | GENEVIEVE | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9046471849 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BLOOM BEHAVIORAL SOLUTIONS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0401X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) |
No ID Information.