Healthcare Provider Details

I. General information

NPI: 1902754542
Provider Name (Legal Business Name): THERAFORM PHYSICAL THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2026
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12658 W WASHINGTON BLVD UNIT 103
LOS ANGELES CA
90066-2300
US

IV. Provider business mailing address

3181 BARBADOS PL
COSTA MESA CA
92626-2301
US

V. Phone/Fax

Practice location:
  • Phone: 310-292-0780
  • Fax:
Mailing address:
  • Phone: 310-292-0780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: JOCELYN RANDALL
Title or Position: PRESIDENT & OWNER
Credential: DPT
Phone: 310-292-0780