Healthcare Provider Details

I. General information

NPI: 1235691510
Provider Name (Legal Business Name): DESERT BLOOM PLASTIC SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2019
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446 S MALL DR STE 1
ST GEORGE UT
84790-4944
US

IV. Provider business mailing address

446 S MALL DR STE 1
ST GEORGE UT
84790-4944
US

V. Phone/Fax

Practice location:
  • Phone: 435-627-8150
  • Fax:
Mailing address:
  • Phone: 435-627-8150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JORDAN WALLIN
Title or Position: PRESIDENT
Credential: MD
Phone: 435-627-8150