Provider Demographics
NPI:1447003108
Name:BLOOM WELLNESS DIRECT PRIMARY CARE, PLLC
Entity type:Organization
Organization Name:BLOOM WELLNESS DIRECT PRIMARY CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:BLERTA
Authorized Official - Middle Name:LICI
Authorized Official - Last Name:GAQI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-509-0055
Mailing Address - Street 1:7112 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-1503
Mailing Address - Country:US
Mailing Address - Phone:248-509-0055
Mailing Address - Fax:626-517-5630
Practice Address - Street 1:7112 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1503
Practice Address - Country:US
Practice Address - Phone:248-509-0055
Practice Address - Fax:626-517-5630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-10
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty