Provider Demographics
NPI:1134827900
Name:BLOSSOM NUTRITION SERVICES
Entity type:Organization
Organization Name:BLOSSOM NUTRITION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TISDALE
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LDN
Authorized Official - Phone:254-458-6647
Mailing Address - Street 1:8251 LAUREL LAKES WAY
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-6793
Mailing Address - Country:US
Mailing Address - Phone:254-458-6647
Mailing Address - Fax:
Practice Address - Street 1:8251 LAUREL LAKES WAY
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34119-6793
Practice Address - Country:US
Practice Address - Phone:254-458-6647
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty