MEDICARE: BLOOM AT WILLOW, LLC

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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1669255931
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOOM AT WILLOW, LLC

Provider Business Mailing Address
First Line	:	260 E BROWN ST STE 315
Second Line	:
City	:	BIRMINGHAM
State	:	MI
Zip	:	48009-6232
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2725 LAKE CIRCLE DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-4931
Country	:	US
Telephone Number	:	317-334-9400
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SCOTT KANTOR
Credential	:
Telephone Number	:	312-282-4050

Provider Enumeration Date	:	08/18/2023
Last Update Date	:	08/18/2023

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Directions to “BLOOM AT WILLOW, LLC ” Practice Location

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