Provider Demographics
NPI:1841945680
Name:MY BLOOMING HEALTH LAB, INC
Entity type:Organization
Organization Name:MY BLOOMING HEALTH LAB, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DANITA
Authorized Official - Middle Name:L
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 STE 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 STE 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:2022-02-21
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physicianGroup - Single Specialty