Provider Demographics
NPI:1376282558
Name:BLOOM TOWN LLC
Entity Type:Organization
Organization Name:BLOOM TOWN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:AQUILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-816-5357
Mailing Address - Street 1:491 BALTIMORE PIKE STE 1213
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:19064-3810
Mailing Address - Country:US
Mailing Address - Phone:267-816-5357
Mailing Address - Fax:
Practice Address - Street 1:491 BALTIMORE PIKE STE 1213
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:19064-3810
Practice Address - Country:US
Practice Address - Phone:267-816-5357
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-03
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty