Healthcare Provider Details

I. General information

NPI: 1255269254
Provider Name (Legal Business Name): CHARLES ERIC BLOOMQUIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1865 9TH ST
SANTA MONICA CA
90404-4501
US

IV. Provider business mailing address

214 4TH AVE
VENICE CA
90291-2618
US

V. Phone/Fax

Practice location:
  • Phone: 310-314-6200
  • Fax:
Mailing address:
  • Phone: 805-338-2854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number25410
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: