Healthcare Provider Details

I. General information

NPI: 1437033511
Provider Name (Legal Business Name): BLOSSOM OSTOMY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2025
Last Update Date: 08/02/2025
Certification Date: 08/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13488 MAXELLA AVE APT 626
MARINA DEL REY CA
90292-4304
US

IV. Provider business mailing address

13488 MAXELLA AVE APT 626
MARINA DEL REY CA
90292-4304
US

V. Phone/Fax

Practice location:
  • Phone: 617-224-2698
  • Fax:
Mailing address:
  • Phone: 617-224-2698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name: NINA HAYES
Title or Position: FOUNDER
Credential:
Phone: 617-224-2698