Provider Demographics
NPI:1669255931
Name:BLOOM AT WILLOW, LLC
Entity type:Organization
Organization Name:BLOOM AT WILLOW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:KANTOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-282-4050
Mailing Address - Street 1:260 E BROWN ST STE 315
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2725 LAKE CIRCLE DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-4931
Practice Address - Country:US
Practice Address - Phone:317-334-9400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-18
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility