Healthcare Provider Details

I. General information

NPI: 1942121520
Provider Name (Legal Business Name): BLOOM ASSISTED LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9016 MORGAN AVE S
BLOOMINGTON MN
55431-2218
US

IV. Provider business mailing address

9016 MORGAN AVE S
BLOOMINGTON MN
55431-2218
US

V. Phone/Fax

Practice location:
  • Phone: 612-432-0203
  • Fax: 612-587-1080
Mailing address:
  • Phone:
  • Fax: 612-587-1080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number
License Number State

VIII. Authorized Official

Name: OSMAN SHIRE
Title or Position: OWNER
Credential:
Phone: 612-432-0203