Provider Demographics
NPI:1558861120
Name:BLOOM OF GRACE REHAB LLC
Entity Type:Organization
Organization Name:BLOOM OF GRACE REHAB LLC
Other - Org Name:SUREST PATH RECOVERY CENTER OF BLOOMVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:HUNT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-332-3378
Mailing Address - Street 1:441 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:GREEN SPRINGS
Mailing Address - State:OH
Mailing Address - Zip Code:44836-9689
Mailing Address - Country:US
Mailing Address - Phone:419-332-3378
Mailing Address - Fax:419-639-2519
Practice Address - Street 1:22 CLINTON ST
Practice Address - Street 2:
Practice Address - City:BLOOMVILLE
Practice Address - State:OH
Practice Address - Zip Code:44818-9399
Practice Address - Country:US
Practice Address - Phone:419-983-4100
Practice Address - Fax:419-983-4103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-20
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility