Provider Demographics
NPI:1205272788
Name:MY BLOOMING HEALTH MOBILE, LLC
Entity type:Organization
Organization Name:MY BLOOMING HEALTH MOBILE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:314-942-3272
Mailing Address - Street 1:2040 WOODSON RD # 204A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63114-5697
Mailing Address - Country:US
Mailing Address - Phone:314-942-3273
Mailing Address - Fax:314-584-2205
Practice Address - Street 1:2040 WOODSON RD # 204A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63114-5697
Practice Address - Country:US
Practice Address - Phone:314-942-3273
Practice Address - Fax:314-584-2205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-10
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1309649261QM2500X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1080096Medicaid
MOMA4774Medicare PIN