MEDICARE: BLOOM TO BE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1053811612
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOOM TO BE

Provider Business Mailing Address
First Line	:	8141 DARTMOOR AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-2152
Country	:	US
Telephone Number	:	702-785-1918
Fax Number	:

Provider Business Practice Location Address
First Line	:	8141 DARTMOOR AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-2152
Country	:	US
Telephone Number	:	702-785-1918
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JINEVA MCALISTER
Credential	:
Telephone Number	:	702-785-1918

Provider Enumeration Date	:	02/20/2018
Last Update Date	:	02/20/2018

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Directions to “BLOOM TO BE ” Practice Location

Language	Start Address	Practice Location

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