1033831227 NPI number — BLOOM INTEGRATIVE WELLNESS CENTER OF SOUTH LAKE, LLC

Table of content: (NPI 1033831227)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033831227 NPI number — BLOOM INTEGRATIVE WELLNESS CENTER OF SOUTH LAKE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLOOM INTEGRATIVE WELLNESS CENTER OF SOUTH LAKE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033831227
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
539 W COMMERCE ST # 4488
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75208-1953
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-864-8928
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14114 DALLAS PKWY STE 310
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75254-1315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
844-864-8928
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/14/2022

Additional Information

Authorized Official

Authorized Official Last Name:
REYNOLDS
Authorized Official First Name:
TIFFANY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
931-980-1911

Provider Taxonomy Codes

  • Taxonomy code: 261QA0005X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LW0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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