=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285584052
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVERBLOOM HOME LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2026
-----------------------------------------------------
Last Update Date | 02/02/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 144 BROWNELL ST SE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49548-7702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-276-8612
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1
-----------------------------------------------------
City | OSHTEMO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49077-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | MICHELLE WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 574-276-8612
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------