Healthcare Provider Details

I. General information

NPI: 1447405964
Provider Name (Legal Business Name): FUNCTION FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2008
Last Update Date: 11/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3323 CARMEL MOUNTAIN RD SUITE 200
SAN DIEGO CA
92121-1035
US

IV. Provider business mailing address

3323 CARMEL MOUNTAIN RD SUITE 200
SAN DIEGO CA
92121-1035
US

V. Phone/Fax

Practice location:
  • Phone: 858-720-0991
  • Fax: 858-720-0992
Mailing address:
  • Phone: 858-720-0991
  • Fax: 858-720-0992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 26653
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 24080
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 26678
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT 26678
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 26571
License Number StateCA

VIII. Authorized Official

Name: BRETT W BLOOM
Title or Position: CEO
Credential: DPT
Phone: 619-229-3909