Provider Demographics
NPI:1669205076
Name:CEDARBLOOM, LLC
Entity type:Organization
Organization Name:CEDARBLOOM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLALEYE
Authorized Official - Middle Name:AUGUSTINE
Authorized Official - Last Name:OLOWOOKERE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:312-451-6917
Mailing Address - Street 1:4101 WILLIAM D TATE AVE STE 212
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-5726
Mailing Address - Country:US
Mailing Address - Phone:312-451-6917
Mailing Address - Fax:
Practice Address - Street 1:4101 WILLIAM D TATE AVE STE 212
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-5726
Practice Address - Country:US
Practice Address - Phone:312-451-6917
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care