Healthcare Provider Details

I. General information

NPI: 1205272788
Provider Name (Legal Business Name): MY BLOOMING HEALTH MOBILE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2013
Last Update Date: 11/09/2021
Certification Date: 10/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

2040 WOODSON RD # 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 TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number1309649
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: DANITA SMITH
Title or Position: DIRECTOR
Credential: RN
Phone: 314-942-3272