Provider Demographics
NPI:1366445074
Name:BLOSSOM VIEW NURSING HOME, INC.
Entity Type:Organization
Organization Name:BLOSSOM VIEW NURSING HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NAOMI
Authorized Official - Middle Name:
Authorized Official - Last Name:WENTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-483-9118
Mailing Address - Street 1:6884 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:SODUS
Mailing Address - State:NY
Mailing Address - Zip Code:14551-9303
Mailing Address - Country:US
Mailing Address - Phone:315-483-9118
Mailing Address - Fax:315-483-9432
Practice Address - Street 1:6884 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:SODUS
Practice Address - State:NY
Practice Address - Zip Code:14551-9303
Practice Address - Country:US
Practice Address - Phone:315-483-9118
Practice Address - Fax:315-483-9432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5828301N261QR0400X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5828301NOtherOPERATING CERTIFICATE #
NY00997604Medicaid
NY335378Medicare Oscar/Certification