Provider Demographics
NPI:1679846141
Name:BLOSSOM BIRTH CENTER
Entity Type:Organization
Organization Name:BLOSSOM BIRTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEAD PHYSICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITEHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-256-7766
Mailing Address - Street 1:2928 N 18TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7705
Mailing Address - Country:US
Mailing Address - Phone:623-322-0730
Mailing Address - Fax:623-374-4592
Practice Address - Street 1:2928 N 18TH PL
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7705
Practice Address - Country:US
Practice Address - Phone:623-322-0730
Practice Address - Fax:623-374-4592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC4901261QB0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthing