Provider Demographics
NPI:1225566268
Name:BLOOMIVERSE, LLC
Entity Type:Organization
Organization Name:BLOOMIVERSE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLTONIAK
Authorized Official - Suffix:
Authorized Official - Credentials:MT-BC
Authorized Official - Phone:716-982-5170
Mailing Address - Street 1:73 ROVNER PL
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-4205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7821 ERIE RD
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:NY
Practice Address - Zip Code:14047-9502
Practice Address - Country:US
Practice Address - Phone:716-549-0585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-02
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic TherapistGroup - Multi-Specialty