MEDICARE: BLOMBORN INC.

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	253J00000X	Foster Care Agency	15989	UT

General Provider Information

NPI Number	:	1992017040
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOMBORN INC.

Provider Business Mailing Address
First Line	:	3155 S HIDDEN VALLEY DR
Second Line	:	#145
City	:	ST GEORGE
State	:	UT
Zip	:	84790-6671
Country	:	US
Telephone Number	:	435-773-2488
Fax Number	:	435-773-9925

Provider Business Practice Location Address
First Line	:	3155 S HIDDEN VALLEY DR
Second Line	:	#145
City	:	ST GEORGE
State	:	UT
Zip	:	84790-6671
Country	:	US
Telephone Number	:	435-773-2488
Fax Number	:	435-773-9925

Authorized Official
Title or Position	:	OWNER
Name	:	MR. MICHAEL JAMES BLOMQUIST
Credential	:	MSW
Telephone Number	:	435-773-2488

Provider Enumeration Date	:	07/06/2010
Last Update Date	:	07/06/2010

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