Healthcare Provider Details

I. General information

NPI: 1861724585
Provider Name (Legal Business Name): MOUNTAIN BLOOM ORIENTAL MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2010
Last Update Date: 02/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MERCADO ST SUITE 150
DURANGO CO
81301-7306
US

IV. Provider business mailing address

454 HIGH TRAILS DR
DURANGO CO
81301-6302
US

V. Phone/Fax

Practice location:
  • Phone: 970-769-8730
  • Fax: 970-375-2207
Mailing address:
  • Phone: 970-769-8730
  • Fax: 970-375-2207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number993
License Number StateCO

VIII. Authorized Official

Name: CLAUDIA G BLETH
Title or Position: OWNER/PRACTITIONER
Credential: L.AC., RN
Phone: 970-769-8730