Healthcare Provider Details

I. General information

NPI: 1760956031
Provider Name (Legal Business Name): BLOOM AND GROW PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2019
Last Update Date: 07/01/2022
Certification Date: 07/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 BURRO AVE
CLOUDCROFT NM
88317-7719
US

IV. Provider business mailing address

PO BOX 1902
CLOUDCROFT NM
88317-1902
US

V. Phone/Fax

Practice location:
  • Phone: 575-682-2002
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SUSAN BRUCE
Title or Position: OWNER
Credential: CPNP
Phone: 575-921-2318