Healthcare Provider Details

I. General information

NPI: 1750942207
Provider Name (Legal Business Name): BLOOM NEW MEXICO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 05/06/2020
Certification Date: 05/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2930 E MAIN ST
FARMINGTON NM
87402-7624
US

IV. Provider business mailing address

50 HENRY ST
CORTEZ CO
81321-3012
US

V. Phone/Fax

Practice location:
  • Phone: 505-326-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SPENCER SMITH
Title or Position: CEO
Credential:
Phone: 970-565-1919