Healthcare Provider Details

I. General information

NPI: 1558861120
Provider Name (Legal Business Name): BLOOM OF GRACE REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2018
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 CLINTON ST
BLOOMVILLE OH
44818-9399
US

IV. Provider business mailing address

441 N BROADWAY ST
GREEN SPRINGS OH
44836-9689
US

V. Phone/Fax

Practice location:
  • Phone: 419-983-4100
  • Fax: 419-983-4103
Mailing address:
  • Phone: 419-332-3378
  • Fax: 419-639-2519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: KATHY KAY HUNT
Title or Position: ADMINISTRATOR
Credential:
Phone: 419-332-3378