Healthcare Provider Details

I. General information

NPI: 1710635545
Provider Name (Legal Business Name): SEGUARO BLOSSOM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2022
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 W GROVE PKWY APT 2029
TEMPE AZ
85283-8422
US

IV. Provider business mailing address

909 W GROVE PKWY APT 2029
TEMPE AZ
85283-8422
US

V. Phone/Fax

Practice location:
  • Phone: 775-287-9463
  • Fax:
Mailing address:
  • Phone: 775-287-9463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. LARYSSA IKEHARA
Title or Position: OWNER
Credential:
Phone: 775-287-9463