Healthcare Provider Details

I. General information

NPI: 1174242564
Provider Name (Legal Business Name): ZOOM THERAPY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2022
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22792 CENTRE DR STE 104
LAKE FOREST CA
92630-6311
US

IV. Provider business mailing address

22792 CENTRE DR STE 104
LAKE FOREST CA
92630-6311
US

V. Phone/Fax

Practice location:
  • Phone: 949-606-4681
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TYLER MICHAELIS
Title or Position: MANAGING MEMBER
Credential:
Phone: 949-606-4681