Healthcare Provider Details

I. General information

NPI: 1982356556
Provider Name (Legal Business Name): BLOSSOM HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2022
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7165 E UNIVERSITY DR STE 154
MESA AZ
85207-6412
US

IV. Provider business mailing address

2109 DUNE DR
LAS VEGAS NV
89106-1982
US

V. Phone/Fax

Practice location:
  • Phone: 480-564-1829
  • Fax:
Mailing address:
  • Phone: 702-773-7723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ERNEST OLIVER
Title or Position: OWNER
Credential:
Phone: 702-773-7723