Provider Demographics
NPI:1750119939
Name:BLOSSOM MANOR LLC
Entity type:Organization
Organization Name:BLOSSOM MANOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF END USER/ PROGRAM PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:CRASHONDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:DEWALT
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:832-579-4545
Mailing Address - Street 1:3207 HAYDEN SPRINGS CT
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77396-3097
Mailing Address - Country:US
Mailing Address - Phone:832-579-4545
Mailing Address - Fax:
Practice Address - Street 1:3207 HAYDEN SPRINGS CT
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77396-3097
Practice Address - Country:US
Practice Address - Phone:832-579-4545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-22
Last Update Date:2024-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities