Provider Demographics
NPI:1801331095
Name:BLOOM RECOVERY TREATMENT CENTER
Entity type:Organization
Organization Name:BLOOM RECOVERY TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEON
Authorized Official - Middle Name:
Authorized Official - Last Name:TONYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:844-842-5666
Mailing Address - Street 1:4809 LOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-1035
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4809 LOWELL AVE
Practice Address - Street 2:
Practice Address - City:LA CRESCENTA
Practice Address - State:CA
Practice Address - Zip Code:91214-1035
Practice Address - Country:US
Practice Address - Phone:844-842-5666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-27
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility