Bloom Primary Tx, PLLC
Family Medicine in Southlake, TX. Organization (NPI-2).
NPI number1275901340
StatusActive
Last updated in NPPESSep 21, 2026
Details
- NPI
- 1275901340
- Entity type
- Organization (NPI-2)
- Legal business name
- Bloom Primary Tx, PLLC
- Organization subpart
- No
- Enumeration date
- Sep 8, 2015
- Certification date
- Sep 21, 2026
- Last updated
- Sep 21, 2026
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 207Q00000X | Family Medicine | P2012 | TX | Yes |
| 363LF0000X | Nurse Practitioner, Family | 617313 | TX |
Practice location
545 S Nolen DrSouthlake, TX 76092-9176
Phone 303-993-1330
Mailing address
12600 W Colfax Ave Ste B200Lakewood, CO 80215-3736
Phone 303-993-1330 · Fax 303-284-4082
Authorized official
Debra Kay Moon Wadelton
Authorized Official
7209231250
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