1003649872 NPI number — INFANTS IN BLOOM

Table of content: (NPI 1003649872)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003649872 NPI number — INFANTS IN BLOOM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INFANTS IN BLOOM
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003649872
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 795
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HANOVER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47243-0795
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 WEST STREET
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47250-3344
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-599-6620
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/26/2024

Additional Information

Authorized Official

Authorized Official Last Name:
MOUSER
Authorized Official First Name:
MEGAN
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
812-820-4055

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1689960429 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1376577767 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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