Healthcare Provider Details

I. General information

NPI: 1093667750
Provider Name (Legal Business Name): BLOOM PRIMARY MO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2026
Last Update Date: 02/13/2026
Certification Date: 02/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 MARYVILLE CENTRE DR STE 340
SAINT LOUIS MO
63141-5831
US

IV. Provider business mailing address

12600 W COLFAX AVE STE B200
LAKEWOOD CO
80215-3736
US

V. Phone/Fax

Practice location:
  • Phone: 720-923-1250
  • Fax:
Mailing address:
  • Phone: 720-923-1250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBRA KAY MOON-WADELTON
Title or Position: REVENUE CYCLE MANAGER
Credential: MOON-WADELTON
Phone: 720-923-1250