Provider Demographics
NPI:1790301224
Name:BLOSSOM AGENCY
Entity Type:Organization
Organization Name:BLOSSOM AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DUY
Authorized Official - Middle Name:
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:682-367-9149
Mailing Address - Street 1:209 CHASEMORE LN
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76018-1084
Mailing Address - Country:US
Mailing Address - Phone:682-367-9149
Mailing Address - Fax:
Practice Address - Street 1:209 CHASEMORE LN
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76018-1084
Practice Address - Country:US
Practice Address - Phone:682-367-9149
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-20
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1790301224Medicaid