Healthcare Provider Details

I. General information

NPI: 1841945680
Provider Name (Legal Business Name): MY BLOOMING HEALTH LAB, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2022
Last Update Date: 02/24/2022
Certification Date: 02/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 WOODSON RD STE 204A
SAINT LOUIS MO
63114-5697
US

IV. Provider business mailing address

2040 WOODSON RD STE 204A
SAINT LOUIS MO
63114-5697
US

V. Phone/Fax

Practice location:
  • Phone: 314-942-3273
  • Fax: 314-584-2205
Mailing address:
  • Phone: 314-942-3273
  • Fax: 314-584-2205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number
License Number State

VIII. Authorized Official

Name: MS. DANITA L SMITH
Title or Position: OWNER
Credential: RN
Phone: 314-942-3272