MEDICARE: BLOSSOM RIDGE LONG TERM CARE CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1316306970
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOSSOM RIDGE LONG TERM CARE CORPORATION

Provider Business Mailing Address
First Line	:	10143 BLOSSOM RIDGE DR
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95757-2512
Country	:	US
Telephone Number	:	916-284-4129
Fax Number	:	916-647-3425

Provider Business Practice Location Address
First Line	:	10143 BLOSSOM RIDGE DR
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95757-2512
Country	:	US
Telephone Number	:	916-284-4129
Fax Number	:	916-647-3425

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	JANET AGUSTIN
Credential	:
Telephone Number	:	916-284-4129

Provider Enumeration Date	:	02/11/2016
Last Update Date	:	02/11/2016

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