Provider Demographics
NPI:1053494799
Name:BLOSSOM HILL CARE CENTER INC
Entity Type:Organization
Organization Name:BLOSSOM HILL CARE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-635-5567
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:12496 PRINCETON ROAD
Mailing Address - City:HUNTSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44046-0369
Mailing Address - Country:US
Mailing Address - Phone:440-635-5567
Mailing Address - Fax:440-636-5601
Practice Address - Street 1:12496 PRINCETON ROAD
Practice Address - Street 2:
Practice Address - City:HUNTSBURG
Practice Address - State:OH
Practice Address - Zip Code:44046-0369
Practice Address - Country:US
Practice Address - Phone:440-635-5567
Practice Address - Fax:440-636-5601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6360314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0321664Medicaid
OH0321664Medicaid