Healthcare Provider Details

I. General information

NPI: 1649080672
Provider Name (Legal Business Name): BLOOM CARE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2025
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

969 2ND ST SE STE 301
CHARLOTTESVILLE VA
22902-6172
US

IV. Provider business mailing address

969 2ND ST SE STE 301
CHARLOTTESVILLE VA
22902-6172
US

V. Phone/Fax

Practice location:
  • Phone: 804-707-7284
  • Fax: 804-710-2024
Mailing address:
  • Phone: 804-707-7284
  • Fax: 804-710-2024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MISS TENYAH JOHNSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 804-707-7284