Provider Demographics
NPI:1215640693
Name:BLOOM & BEYOND LLC
Entity type:Organization
Organization Name:BLOOM & BEYOND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANTE
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:MS EDUCATION
Authorized Official - Phone:240-803-5263
Mailing Address - Street 1:3081 OLD WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-3122
Mailing Address - Country:US
Mailing Address - Phone:240-803-5263
Mailing Address - Fax:
Practice Address - Street 1:3081 OLD WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-3122
Practice Address - Country:US
Practice Address - Phone:240-803-5263
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-02
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency