Healthcare Provider Details

I. General information

NPI: 1376282558
Provider Name (Legal Business Name): BLOOM TOWN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2022
Last Update Date: 07/28/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

491 BALTIMORE PIKE STE 1213
SPRINGFIELD PA
19064-3810
US

IV. Provider business mailing address

491 BALTIMORE PIKE STE 1213
SPRINGFIELD PA
19064-3810
US

V. Phone/Fax

Practice location:
  • Phone: 267-816-5357
  • Fax:
Mailing address:
  • Phone: 267-816-5357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: AQUILLA ALI
Title or Position: CLINICIAN
Credential:
Phone: 267-816-5357