Healthcare Provider Details

I. General information

NPI: 1366904872
Provider Name (Legal Business Name): BLOOM AT KOKOMO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 S DIXON RD
KOKOMO IN
46902-6403
US

IV. Provider business mailing address

260 E BROWN ST STE 315
BIRMINGHAM MI
48009-6232
US

V. Phone/Fax

Practice location:
  • Phone: 765-455-2828
  • Fax:
Mailing address:
  • Phone: 248-642-2914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: SCOTT KANTOR
Title or Position: OWNER
Credential:
Phone: 248-642-2914