Healthcare Provider Details

I. General information

NPI: 1932240314
Provider Name (Legal Business Name): BLOSSOM HILL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 OAK AVE SW
MONTGOMERY MN
56069-1243
US

IV. Provider business mailing address

100 OAK AVE SW
MONTGOMERY MN
56069
US

V. Phone/Fax

Practice location:
  • Phone: 507-364-5312
  • Fax: 507-364-5908
Mailing address:
  • Phone: 507-364-5312
  • Fax: 507-364-5908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number1072342-1-HCBS
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number1072346-1-H
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number1044272-1-AFC
License Number StateMN

VIII. Authorized Official

Name: MRS. PAULA MARIE BEULKE
Title or Position: DIRECTOR
Credential:
Phone: 507-364-5312