Provider Demographics
NPI:1043663693
Name:BLOSSOM FAMILY CHIROPRACTIC
Entity type:Organization
Organization Name:BLOSSOM FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SAVANNAH
Authorized Official - Middle Name:IRBY
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:813-505-2671
Mailing Address - Street 1:360 CENTRAL AVE
Mailing Address - Street 2:STE 480
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-3857
Mailing Address - Country:US
Mailing Address - Phone:727-498-5643
Mailing Address - Fax:
Practice Address - Street 1:360 CENTRAL AVE
Practice Address - Street 2:STE 480
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-3857
Practice Address - Country:US
Practice Address - Phone:727-498-5643
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 11817111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty