Provider Demographics
NPI:1174020853
Name:TAO BLOSSOM PLLC
Entity Type:Organization
Organization Name:TAO BLOSSOM PLLC
Other - Org Name:TAO BLOSSOM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, LICENSED ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:DEVON
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MAC, DIPLOM, LAC
Authorized Official - Phone:512-577-9802
Mailing Address - Street 1:1001 S CAPITAL OF TEXAS HWY STE 210
Mailing Address - Street 2:
Mailing Address - City:WEST LAKE HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:78746-6450
Mailing Address - Country:US
Mailing Address - Phone:804-363-7559
Mailing Address - Fax:
Practice Address - Street 1:1001 S CAPITAL OF TEXAS HWY STE 210
Practice Address - Street 2:
Practice Address - City:WEST LAKE HILLS
Practice Address - State:TX
Practice Address - Zip Code:78746-6450
Practice Address - Country:US
Practice Address - Phone:804-363-7559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01800171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty