Provider Demographics
NPI:1164289690
Name:BLOSSOM WELLNESS LLC
Entity Type:Organization
Organization Name:BLOSSOM WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELVIS
Authorized Official - Middle Name:TAMBI
Authorized Official - Last Name:STARLLONE
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:651-410-7955
Mailing Address - Street 1:625 HAYWARD AVE N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-7127
Mailing Address - Country:US
Mailing Address - Phone:651-410-7955
Mailing Address - Fax:
Practice Address - Street 1:625 HAYWARD AVE N
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-7127
Practice Address - Country:US
Practice Address - Phone:651-410-7955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-01
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center