Provider Demographics
NPI:1922751205
Name:THE BLOOM COLLECTIVE LLC
Entity Type:Organization
Organization Name:THE BLOOM COLLECTIVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:MS
Authorized Official - First Name:TANAY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-394-0694
Mailing Address - Street 1:2000 GREENMOUNT AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-6164
Mailing Address - Country:US
Mailing Address - Phone:202-394-0694
Mailing Address - Fax:
Practice Address - Street 1:2000 GREENMOUNT AVE STE 101
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-6164
Practice Address - Country:US
Practice Address - Phone:202-394-0694
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0000000000Medicaid