Provider Demographics
NPI:1750444246
Name:BLOSSOM SOUTH, LLC
Entity Type:Organization
Organization Name:BLOSSOM SOUTH, LLC
Other - Org Name:BLOSSOM SOUTH NURSING AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-679-1500
Mailing Address - Street 1:1175 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-1613
Mailing Address - Country:US
Mailing Address - Phone:585-442-0450
Mailing Address - Fax:585-442-2855
Practice Address - Street 1:1175 MONROE AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-1613
Practice Address - Country:US
Practice Address - Phone:585-442-0450
Practice Address - Fax:585-442-2855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2701351N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355573Medicaid
NY183542CIOtherPREFERRED CARE
NY183542CIOtherPREFERRED CARE