Provider Demographics
NPI:1982225561
Name:BLOOM LIFECARE
Entity Type:Organization
Organization Name:BLOOM LIFECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:CSA, CLTC
Authorized Official - Phone:510-835-9362
Mailing Address - Street 1:3820 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5616
Mailing Address - Country:US
Mailing Address - Phone:510-835-9362
Mailing Address - Fax:510-835-9362
Practice Address - Street 1:3820 BROADWAY
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5616
Practice Address - Country:US
Practice Address - Phone:510-835-9362
Practice Address - Fax:510-835-9362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA014700063OtherCA DSS HOME CARE AIDE REGISTRY