MEDICARE: BLOOM INTEGRATIVE WELLNESS CENTER OF SOUTH LAKE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA0005X	Ambulatory Family Planning Facility
2	363LW0102X	Women's Health Nurse Practitioner

General Provider Information

NPI Number	:	1033831227
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOOM INTEGRATIVE WELLNESS CENTER OF SOUTH LAKE, LLC

Provider Business Mailing Address
First Line	:	539 W COMMERCE ST # 4488
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75208-1953
Country	:	US
Telephone Number	:	844-864-8928
Fax Number	:

Provider Business Practice Location Address
First Line	:	14114 DALLAS PKWY STE 310
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75254-1315
Country	:	US
Telephone Number	:	844-864-8928
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	TIFFANY REYNOLDS
Credential	:	WHNP
Telephone Number	:	931-980-1911

Provider Enumeration Date	:	09/14/2022
Last Update Date	:	01/27/2026

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