Provider Demographics
NPI:1982356556
Name:BLOSSOM HEALTH SERVICES LLC
Entity type:Organization
Organization Name:BLOSSOM HEALTH SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-773-7723
Mailing Address - Street 1:2109 DUNE DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-1982
Mailing Address - Country:US
Mailing Address - Phone:702-773-7723
Mailing Address - Fax:
Practice Address - Street 1:7165 E UNIVERSITY DR STE 154
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-6412
Practice Address - Country:US
Practice Address - Phone:480-564-1829
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-25
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty