Provider Demographics
NPI:1598414393
Name:BLOSSOM SUPPORT COORDINATION LLC
Entity Type:Organization
Organization Name:BLOSSOM SUPPORT COORDINATION LLC
Other - Org Name:BLOSSOM SUPPORT COORDINATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LOGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUILLORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-373-4114
Mailing Address - Street 1:9800 AIRLINE HWY STE 253
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-8006
Mailing Address - Country:US
Mailing Address - Phone:225-409-7390
Mailing Address - Fax:225-250-1514
Practice Address - Street 1:9800 AIRLINE HWY STE 253
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-8006
Practice Address - Country:US
Practice Address - Phone:225-409-7390
Practice Address - Fax:225-250-1514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-21
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2570781Medicaid