Provider Demographics
NPI:1720459894
Name:BLOOMIN' BABIES BIRTH CENTER, LLC
Entity Type:Organization
Organization Name:BLOOMIN' BABIES BIRTH CENTER, LLC
Other - Org Name:BLOOMIN' BABIES GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CNM
Authorized Official - Prefix:
Authorized Official - First Name:PATTY
Authorized Official - Middle Name:
Authorized Official - Last Name:KANDIKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-279-4545
Mailing Address - Street 1:2241 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-7423
Mailing Address - Country:US
Mailing Address - Phone:970-589-4143
Mailing Address - Fax:
Practice Address - Street 1:2241 N 7TH ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-7423
Practice Address - Country:US
Practice Address - Phone:970-549-1711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-14
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Multi-Specialty
No176B00000XOther Service ProvidersMidwifeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO62975862Medicaid