Healthcare Provider Details

I. General information

NPI: 1710812987
Provider Name (Legal Business Name): BLOSSOM LANE HOME CARE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51562 DURANGO CT
SOUTH BEND IN
46628-8446
US

IV. Provider business mailing address

51562 DURANGO CT
SOUTH BEND IN
46628-8446
US

V. Phone/Fax

Practice location:
  • Phone: 574-355-3333
  • Fax:
Mailing address:
  • Phone: 574-355-3333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: GLADYS MARONDERA
Title or Position: CEO
Credential: RN
Phone: 574-355-3333