Provider Demographics
NPI:1932240314
Name:BLOSSOM HILL CORPORATION
Entity Type:Organization
Organization Name:BLOSSOM HILL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BEULKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-364-5312
Mailing Address - Street 1:100 OAK AVE SW
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:MN
Mailing Address - Zip Code:56069
Mailing Address - Country:US
Mailing Address - Phone:507-364-5312
Mailing Address - Fax:507-364-5908
Practice Address - Street 1:100 OAK AVE SW
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:MN
Practice Address - Zip Code:56069-1243
Practice Address - Country:US
Practice Address - Phone:507-364-5312
Practice Address - Fax:507-364-5908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1072342-1-HCBS261QM0801X
MN1072346-1-H310400000X
MN1044272-1-AFC320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN231653100Medicaid
MN953485000OtherMEDICAL ASSISTANCE