Provider Demographics
NPI:1639652266
Name:BLOOM BEHAVIORAL COMMUNITY
Entity Type:Organization
Organization Name:BLOOM BEHAVIORAL COMMUNITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JEANNETTE
Authorized Official - Middle Name:L
Authorized Official - Last Name:EVERETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-434-2612
Mailing Address - Street 1:819 W SAN MIGUEL AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-1744
Mailing Address - Country:US
Mailing Address - Phone:602-434-2612
Mailing Address - Fax:
Practice Address - Street 1:819 W SAN MIGUEL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-1744
Practice Address - Country:US
Practice Address - Phone:602-434-2612
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IRIS HOUSE ASSISTED LIVING, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty