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General NPI Number Information
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NPI Number | 1083421192
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Entity Type | Organization
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Legal Business Name | BLOSSOM LLC
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Dates
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Enumeration Date | 12/12/2024
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Last Update Date | 12/29/2024
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Provider Practice Location Address
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Address Line | 909 N AVALON ST
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City | MEMPHIS
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State | TN
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Zip | 38107-5008
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Country | US
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Telephone | 901-288-5875
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Fax |
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Provider Business Mailing Address
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Address Line | 909 N AVALON ST
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City | MEMPHIS
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State | TN
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Zip | 38107-5008
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Country | US
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Telephone | 901-288-5875
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Fax |
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Authorized Official
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Title or Position | DIETIAN
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Name | MARGARET HERIN
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Credential | MS, RD, LD
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Telephone | 901-288-5875
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133VN1004X
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Taxonomy Name | Pediatric Nutrition Registered Dietitian
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 133VN1501X
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Taxonomy Name | Sports Dietetics Nutrition Registered Dietitian
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number |
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License Number State |
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