Healthcare Provider Details

I. General information

NPI: 1386517035
Provider Name (Legal Business Name): BLOOM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2025
Last Update Date: 09/29/2025
Certification Date: 09/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 W MAIN ST STE 35
MESA AZ
85201-7310
US

IV. Provider business mailing address

114 W MAIN ST STE 35
MESA AZ
85201-7310
US

V. Phone/Fax

Practice location:
  • Phone: 623-296-2943
  • Fax:
Mailing address:
  • Phone: 623-296-2943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number StateNULL

VIII. Authorized Official

Name: CHARAE JACKSON
Title or Position: DIRECTOR
Credential:
Phone: 623-296-2943