Provider Demographics
NPI:1609231539
Name:BLOOMING BUDS MEDICINE
Entity Type:Organization
Organization Name:BLOOMING BUDS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATALIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUNTOVA
Authorized Official - Suffix:
Authorized Official - Credentials:MSOM
Authorized Official - Phone:414-350-8279
Mailing Address - Street 1:3545 E TESCH AVE
Mailing Address - Street 2:# 3
Mailing Address - City:SAINT FRANCIS
Mailing Address - State:WI
Mailing Address - Zip Code:53235-4862
Mailing Address - Country:US
Mailing Address - Phone:414-350-8279
Mailing Address - Fax:
Practice Address - Street 1:333 BISHOPS WAY
Practice Address - Street 2:SUITE 121
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-6226
Practice Address - Country:US
Practice Address - Phone:414-350-8279
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-18
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI823-55171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty