Provider Demographics
NPI:1760956031
Name:BLOOM AND GROW PEDIATRICS LLC
Entity Type:Organization
Organization Name:BLOOM AND GROW PEDIATRICS LLC
Other - Org Name:BLOOM MEDICAL SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:CPNP
Authorized Official - Phone:575-921-2318
Mailing Address - Street 1:PO BOX 1902
Mailing Address - Street 2:
Mailing Address - City:CLOUDCROFT
Mailing Address - State:NM
Mailing Address - Zip Code:88317-1902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1315 BURRO AVE
Practice Address - Street 2:
Practice Address - City:CLOUDCROFT
Practice Address - State:NM
Practice Address - Zip Code:88317-7719
Practice Address - Country:US
Practice Address - Phone:575-682-2002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-18
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1326276395OtherTYPE 1 NPI
NM99120330Medicaid