Provider Demographics
NPI:1235691510
Name:DESERT BLOOM PLASTIC SURGERY LLC
Entity Type:Organization
Organization Name:DESERT BLOOM PLASTIC SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-529-8744
Mailing Address - Street 1:446 S MALL DR STE 1
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-4944
Mailing Address - Country:US
Mailing Address - Phone:435-627-8150
Mailing Address - Fax:
Practice Address - Street 1:446 S MALL DR STE 1
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4944
Practice Address - Country:US
Practice Address - Phone:435-627-8150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-04
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty