Provider Demographics
NPI:1730717471
Name:BLOSSOM HERE
Entity type:Organization
Organization Name:BLOSSOM HERE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:QUIANA
Authorized Official - Middle Name:MESHELL
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-999-3798
Mailing Address - Street 1:9169 DRAYTON LN
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29707-5848
Mailing Address - Country:US
Mailing Address - Phone:201-852-2309
Mailing Address - Fax:201-852-2309
Practice Address - Street 1:101-105 N YORK STREET
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-2972
Practice Address - Country:US
Practice Address - Phone:803-999-3798
Practice Address - Fax:803-636-8201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency