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General NPI Number Information
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NPI Number | 1760872600
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Entity Type | Organization
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Legal Business Name | BLOSSOM MEDSPA & WELLNESS CLINIC, LLC
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Dates
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Enumeration Date | 01/30/2015
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Last Update Date | 01/30/2015
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Provider Practice Location Address
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Address Line | 2304 S BABCOCK ST
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City | MELBOURNE
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State | FL
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Zip | 32901-5308
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Country | US
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Telephone | 321-837-3935
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Fax |
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Provider Business Mailing Address
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Address Line | 2304 S BABCOCK ST
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City | MELBOURNE
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State | FL
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Zip | 32901-5308
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Country | US
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Telephone | 321-837-3935
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. NARESH MANEKLAL DAVDA
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Credential | PA
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Telephone | 321-837-3935
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | PA9101508
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License Number State | FL
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