Healthcare Provider Details

I. General information

NPI: 1497124705
Provider Name (Legal Business Name): BLOOM WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2015
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9798 COORS BLVD NW BLDG C SUITE 101
ALBUQUERQUE NM
87114-6131
US

IV. Provider business mailing address

9798 COORS BLVD NW BLDG C SUITE 101
ALBUQUERQUE NM
87114-6131
US

V. Phone/Fax

Practice location:
  • Phone: 505-639-5147
  • Fax: 505-639-4153
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1057
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: HEATHER JONES
Title or Position: PRESIDENT/OWNER
Credential: DOM
Phone: 505-400-1520