Healthcare Provider Details

I. General information

NPI: 1750711289
Provider Name (Legal Business Name): BRIGHT BEGINNINGS FOR KIDS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2013
Last Update Date: 11/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11965 VENICE BLVD SUITE 408
LOS ANGELES CA
90066-3979
US

IV. Provider business mailing address

11965 VENICE BLVD SUITE 408
LOS ANGELES CA
90066-3979
US

V. Phone/Fax

Practice location:
  • Phone: 310-316-2190
  • Fax: 310-316-2713
Mailing address:
  • Phone: 310-316-2190
  • Fax: 310-316-2713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number1719
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number1719
License Number StateCA

VIII. Authorized Official

Name: DEBRA M SHIROMA
Title or Position: PRESIDENT
Credential:
Phone: 310-316-2190