Provider Demographics
NPI:1811521024
Name:CHERRY BLOSSOM ASSISTED LIVING FACILITY, LLC
Entity type:Organization
Organization Name:CHERRY BLOSSOM ASSISTED LIVING FACILITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CAMILLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLAXTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-987-5406
Mailing Address - Street 1:PO BOX 100126
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32910-0126
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:136 DEAUVILLE AVE NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-3031
Practice Address - Country:US
Practice Address - Phone:321-987-5406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility