Healthcare Provider Details

I. General information

NPI: 1093416273
Provider Name (Legal Business Name): BLOOMWELL PEDIATRIC WELLNESS AND PHYSICAL THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2023
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25255 CABOT RD STE 112
LAGUNA HILLS CA
92653-5507
US

IV. Provider business mailing address

25255 CABOT RD STE 112
LAGUNA HILLS CA
92653-5507
US

V. Phone/Fax

Practice location:
  • Phone: 949-229-0170
  • Fax:
Mailing address:
  • Phone: 949-229-0170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: TAYLOR HENDERSON
Title or Position: PHYSICAL THERAPIST, OWNER
Credential: PT, DPT
Phone: 949-229-0170