Provider Demographics
NPI:1609048602
Name:BURKEBLOSSOM MONICA
Entity Type:Organization
Organization Name:BURKEBLOSSOM MONICA
Other - Org Name:BURKE BLOSSOM MONICA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CAREGIVER
Authorized Official - Prefix:
Authorized Official - First Name:BLOSSOM
Authorized Official - Middle Name:MONICA
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:N/A
Authorized Official - Phone:813-684-3702
Mailing Address - Street 1:907 N TAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510-3121
Mailing Address - Country:US
Mailing Address - Phone:813-684-3702
Mailing Address - Fax:813-684-3702
Practice Address - Street 1:907 N TAYLOR RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-3121
Practice Address - Country:US
Practice Address - Phone:813-684-3702
Practice Address - Fax:813-684-3702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906191311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home