Provider Demographics
NPI:1164251690
Name:BLOSSOM LIGHT CARE LLC
Entity type:Organization
Organization Name:BLOSSOM LIGHT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:MUSIBE
Authorized Official - Last Name:NYETMOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-430-0428
Mailing Address - Street 1:310 W PLEASANT RUN RD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:TX
Mailing Address - Zip Code:75146-1566
Mailing Address - Country:US
Mailing Address - Phone:214-430-0428
Mailing Address - Fax:
Practice Address - Street 1:310 W PLEASANT RUN RD
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:TX
Practice Address - Zip Code:75146-1566
Practice Address - Country:US
Practice Address - Phone:214-430-0428
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care