MEDICARE: BORN TO BLOOM LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1679287254
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BORN TO BLOOM LLC

Provider Business Mailing Address
First Line	:	304 S JONES BLVD # 5654
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89107-2623
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5305 LAKEWOOD CREEK AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89141
Country	:	US
Telephone Number	:	678-480-1149
Fax Number	:

Authorized Official
Title or Position	:	OCCUPATIONAL THERAPIST
Name	:	MRS. QUANEKA HOSKIN-CHASE
Credential	:	MS, OTR/L
Telephone Number	:	678-480-1149

Provider Enumeration Date	:	01/09/2023
Last Update Date	:	01/09/2023

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Directions to “BORN TO BLOOM LLC ” Practice Location

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