Provider Demographics
NPI:1659778421
Name:AWAKEN BLOSSOM FOUNDATION
Entity Type:Organization
Organization Name:AWAKEN BLOSSOM FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MILDRED
Authorized Official - Middle Name:
Authorized Official - Last Name:ABONCE
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:708-613-5690
Mailing Address - Street 1:6142 ROOSEVELT RD # 101
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304-2311
Mailing Address - Country:US
Mailing Address - Phone:708-613-5690
Mailing Address - Fax:
Practice Address - Street 1:6142 ROOSEVELT RD # 101
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304-2311
Practice Address - Country:US
Practice Address - Phone:708-613-5690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-22
Last Update Date:2014-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198000100171100000X
IL227007446174400000X
IL227004827174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty