Basic Information
| Provider Information | |||||||||
| NPI: | 1962656900 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ORION BLOSSOM LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BLOSSOM NURSING & REHABILITATION CENTER-LAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 109 BLOSSOM LN | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444604284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303373033 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 109 BLOSSOM LN | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444604284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303373033 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2008 | ||||||||
| LastUpdateDate: | 11/04/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LOCKHART | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 6144160600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ORION OPERATING SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 36D0953812 | OH | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.