Provider Demographics
NPI:1669067146
Name:ALIVE & BLOSSOM HEALTHCARE LLC
Entity type:Organization
Organization Name:ALIVE & BLOSSOM HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARGALY
Authorized Official - Middle Name:
Authorized Official - Last Name:VALCOURT
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:954-394-4793
Mailing Address - Street 1:190 CHAMPIONS VUE LOOP UNIT 408
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33897-4857
Mailing Address - Country:US
Mailing Address - Phone:954-394-4793
Mailing Address - Fax:
Practice Address - Street 1:190 CHAMPIONS VUE LOOP UNIT 408
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33897-4857
Practice Address - Country:US
Practice Address - Phone:954-394-4793
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0000000OtherN/A