Provider Demographics
NPI:1033831227
Name:BLOOM INTEGRATIVE WELLNESS CENTER OF SOUTHLAKE, LLC
Entity Type:Organization
Organization Name:BLOOM INTEGRATIVE WELLNESS CENTER OF SOUTHLAKE, LLC
Other - Org Name:BLOOM INTEGRATIVE WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:WHNP
Authorized Official - Phone:931-980-1911
Mailing Address - Street 1:539 W COMMERCE ST # 4488
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-1953
Mailing Address - Country:US
Mailing Address - Phone:844-864-8928
Mailing Address - Fax:
Practice Address - Street 1:351 W RANDOL MILL RD # 151
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-5733
Practice Address - Country:US
Practice Address - Phone:844-864-8928
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-14
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty