Healthcare Provider Details

I. General information

NPI: 1376487017
Provider Name (Legal Business Name): ELENA BLOOMQUIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2026
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2078 BIRD RD LOT C3
BRANSON MO
65616-6242
US

IV. Provider business mailing address

2078 BIRD RD LOT C3
BRANSON MO
65616-6242
US

V. Phone/Fax

Practice location:
  • Phone: 909-848-6323
  • Fax:
Mailing address:
  • Phone: 909-848-6323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: