Provider Demographics
NPI:1578186557
Name:BLOOM AND BLOSSOM LLC.
Entity Type:Organization
Organization Name:BLOOM AND BLOSSOM LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:S
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:ALC
Authorized Official - Phone:334-546-4145
Mailing Address - Street 1:527 LEGENDS DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-6585
Mailing Address - Country:US
Mailing Address - Phone:334-233-3361
Mailing Address - Fax:
Practice Address - Street 1:882 PLANTATION WAY STE C
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-2217
Practice Address - Country:US
Practice Address - Phone:334-546-4145
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-25
Last Update Date:2020-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health