Healthcare Provider Details

I. General information

NPI: 1366178105
Provider Name (Legal Business Name): BLOOMINGDALE SENIOR SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2022
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

01546 COUNTY ROAD 665
BLOOMINGDALE MI
49026-8756
US

IV. Provider business mailing address

01546 COUNTY ROAD 665
BLOOMINGDALE MI
49026-8756
US

V. Phone/Fax

Practice location:
  • Phone: 269-512-6163
  • Fax:
Mailing address:
  • Phone: 269-512-6163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: MR. TERRY L MCCULLOUGH
Title or Position: DIRECTOR
Credential: MSW
Phone: 269-512-6163