Provider Demographics
NPI:1609221811
Name:SERVICE IN BLOOM, INC.
Entity Type:Organization
Organization Name:SERVICE IN BLOOM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAMITA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-391-5480
Mailing Address - Street 1:200 E RANDOLPH ST
Mailing Address - Street 2:5100-10
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-6436
Mailing Address - Country:US
Mailing Address - Phone:312-391-5480
Mailing Address - Fax:312-233-0063
Practice Address - Street 1:200 E RANDOLPH ST
Practice Address - Street 2:5100-10
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-6436
Practice Address - Country:US
Practice Address - Phone:312-391-5480
Practice Address - Fax:312-233-0063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3001117253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care