Healthcare Provider Details

I. General information

NPI: 1073442786
Provider Name (Legal Business Name): BLACKBLOOM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 E 670 N
VINEYARD UT
84059-6568
US

IV. Provider business mailing address

7533 S CENTER VIEW CT STE R
WEST JORDAN UT
84084-5526
US

V. Phone/Fax

Practice location:
  • Phone: 530-560-9138
  • Fax:
Mailing address:
  • Phone: 530-425-8114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DARCY GISA
Title or Position: CEO
Credential:
Phone: 530-425-8114