Healthcare Provider Details

I. General information

NPI: 1487500112
Provider Name (Legal Business Name): BLOOMING VIDAS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2026
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3021 E SPRINGS RD
LAS CRUCES NM
88011-5265
US

IV. Provider business mailing address

3021 E SPRINGS RD
LAS CRUCES NM
88011-5265
US

V. Phone/Fax

Practice location:
  • Phone: 575-520-2536
  • Fax:
Mailing address:
  • Phone: 575-520-2536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KILEY GIFFORD
Title or Position: CEO
Credential:
Phone: 575-520-2536