Healthcare Provider Details

I. General information

NPI: 1063341790
Provider Name (Legal Business Name): ABG BLOOM CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 BAY RIDGE PKWY APT 29
BROOKLYN NY
11209-2709
US

IV. Provider business mailing address

402 BAY RIDGE PKWY APT 29
BROOKLYN NY
11209-2709
US

V. Phone/Fax

Practice location:
  • Phone: 347-753-0473
  • Fax:
Mailing address:
  • Phone: 347-753-0473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: NINO TSITSAVA
Title or Position: PRESIDENT
Credential:
Phone: 347-753-0473