Provider Demographics
NPI:1366968612
Name:BLOOM AT ST. PETERSBURG, LLC
Entity type:Organization
Organization Name:BLOOM AT ST. PETERSBURG, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:KANTOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-642-2914
Mailing Address - Street 1:260 E BROWN ST STE 315
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6232
Mailing Address - Country:US
Mailing Address - Phone:1248-642-2914
Mailing Address - Fax:
Practice Address - Street 1:6775 40TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-4939
Practice Address - Country:US
Practice Address - Phone:727-800-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-18
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility