1134933146 NPI number — CEDARBLOOM, LIMITED LIABILITY COMPANY

Table of content: (NPI 1134933146)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134933146 NPI number — CEDARBLOOM, LIMITED LIABILITY COMPANY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CEDARBLOOM, LIMITED LIABILITY COMPANY
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:
1134933146
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
706 CYPRESSWOOD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANSFIELD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76063-7294
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-451-6917
Provider Business Mailing Address Fax Number:
214-945-1009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4101 WILLIAM D TATE AVE STE 212
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAPEVINE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76051-5726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-704-0544
Provider Business Practice Location Address Fax Number:
214-945-1009
Provider Enumeration Date:
02/03/2025

Additional Information

Authorized Official

Authorized Official Last Name:
OLOWOOKERE
Authorized Official First Name:
OLALEYE
Authorized Official Middle Name:
AUGUSTINE
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
312-451-6917

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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