Provider Demographics
NPI:1588051528
Name:BLOSSOMS ASSISTED LIVING 1, LLC
Entity type:Organization
Organization Name:BLOSSOMS ASSISTED LIVING 1, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:STURDGESS HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-257-2162
Mailing Address - Street 1:1312 MARDRAKE RD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-5940
Mailing Address - Country:US
Mailing Address - Phone:386-257-2162
Mailing Address - Fax:386-257-2162
Practice Address - Street 1:1799 SERENO DR
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33896-8603
Practice Address - Country:US
Practice Address - Phone:863-420-1463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLOSSOMS SUPPORT SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10287310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility