Provider Demographics
NPI:1922529478
Name:BLOSSOM ADULT DAY CENTER LLC
Entity Type:Organization
Organization Name:BLOSSOM ADULT DAY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:EKOYATA
Authorized Official - Middle Name:
Authorized Official - Last Name:ULINFUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-237-4226
Mailing Address - Street 1:31023 BIRCHLAWN ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48135-1995
Mailing Address - Country:US
Mailing Address - Phone:734-237-4226
Mailing Address - Fax:
Practice Address - Street 1:31023 BIRCHLAWN ST
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-1995
Practice Address - Country:US
Practice Address - Phone:734-237-4226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-05
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801091539104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty