Provider Demographics
NPI:1316637689
Name:BLOOMING PERSONAL DEVELOPMENT, LLC
Entity type:Organization
Organization Name:BLOOMING PERSONAL DEVELOPMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PROGRAM ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JACQULENE
Authorized Official - Middle Name:TRINETTE
Authorized Official - Last Name:TARVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-536-4318
Mailing Address - Street 1:1730 SHADOWOOD LN STE 370
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-1133
Mailing Address - Country:US
Mailing Address - Phone:904-536-4318
Mailing Address - Fax:
Practice Address - Street 1:1730 SHADOWOOD LN STE 370
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-1133
Practice Address - Country:US
Practice Address - Phone:904-536-4318
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-10
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities