Provider Demographics
NPI:1306722038
Name:WILD BLOOM WELLNESS LLC
Entity type:Organization
Organization Name:WILD BLOOM WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:LAUGHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-331-2232
Mailing Address - Street 1:8050 FREEMANTLE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-4923
Mailing Address - Country:US
Mailing Address - Phone:719-331-2232
Mailing Address - Fax:
Practice Address - Street 1:8050 FREEMANTLE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-4923
Practice Address - Country:US
Practice Address - Phone:719-331-2232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-15
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)