Healthcare Provider Details

I. General information

NPI: 1447140504
Provider Name (Legal Business Name): BLOOM MED, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2025
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 S STEARMAN DR
CHANDLER AZ
85286-2263
US

IV. Provider business mailing address

2301 S STEARMAN DR
CHANDLER AZ
85286-2263
US

V. Phone/Fax

Practice location:
  • Phone: 520-800-5676
  • Fax:
Mailing address:
  • Phone: 520-800-5676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MARK GOFORTH
Title or Position: OWNER
Credential: MHPFNP
Phone: 520-904-7987