Provider Demographics
NPI:1013627405
Name:BLOSSOM CREEKS ASSISTED LIVING 2
Entity Type:Organization
Organization Name:BLOSSOM CREEKS ASSISTED LIVING 2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAJVINDER
Authorized Official - Middle Name:KAUR
Authorized Official - Last Name:SAMRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-598-9515
Mailing Address - Street 1:2770 N BURGAN AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-8972
Mailing Address - Country:US
Mailing Address - Phone:559-598-9515
Mailing Address - Fax:
Practice Address - Street 1:2770 N BURGAN AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-8972
Practice Address - Country:US
Practice Address - Phone:559-598-9515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1497291751Medicaid