Provider Demographics
NPI:1588251524
Name:DESERT BLOOM WELLNESS NV LLC
Entity type:Organization
Organization Name:DESERT BLOOM WELLNESS NV LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAITLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-232-0502
Mailing Address - Street 1:85 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-5604
Mailing Address - Country:US
Mailing Address - Phone:775-453-4149
Mailing Address - Fax:
Practice Address - Street 1:85 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-5604
Practice Address - Country:US
Practice Address - Phone:775-453-4149
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty