Provider Demographics
NPI:1902341548
Name:BLOSSOM CHIROPRACTIC AND NATURAL MEDICINE
Entity Type:Organization
Organization Name:BLOSSOM CHIROPRACTIC AND NATURAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLIVIA
Authorized Official - Middle Name:BRESSY
Authorized Official - Last Name:CASHMORE
Authorized Official - Suffix:
Authorized Official - Credentials:DC, CCN
Authorized Official - Phone:262-220-8500
Mailing Address - Street 1:6106 115TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7274
Mailing Address - Country:US
Mailing Address - Phone:262-220-8500
Mailing Address - Fax:
Practice Address - Street 1:3601 30TH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1695
Practice Address - Country:US
Practice Address - Phone:262-220-8500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5085111NN1001X, 111NP0017X, 111NR0400X
IL038010095111NN1001X, 111NP0017X, 111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Multi-Specialty
No111NP0017XChiropractic ProvidersChiropractorPediatric ChiropractorGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty