Healthcare Provider Details

I. General information

NPI: 1780373290
Provider Name (Legal Business Name): BLOSSOM Q HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2023
Last Update Date: 05/02/2023
Certification Date: 04/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2133 BOYCE CIR
MARIETTA GA
30066-4514
US

IV. Provider business mailing address

650 PONCE DE LEON AVE NE STE 300
ATLANTA GA
30308-1864
US

V. Phone/Fax

Practice location:
  • Phone: 404-595-1697
  • Fax:
Mailing address:
  • Phone: 404-595-1697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: AVANTIKA VARMA
Title or Position: CEO
Credential: MD
Phone: 404-595-1697