=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770355257
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AYUDA MEDICAL, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2023
-----------------------------------------------------
Last Update Date | 10/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 42544 10TH ST W STE G
-----------------------------------------------------
City | LANCASTER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93534-7079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-351-0745
-----------------------------------------------------
Fax | 805-288-6744
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 42544 10TH ST W STE G
-----------------------------------------------------
City | LANCASTER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93534-7079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-351-0745
-----------------------------------------------------
Fax | 805-288-6744
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. MATTHEW LEE BLOOM
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 805-351-0745
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP3300X
-----------------------------------------------------
Taxonomy Name | Pain Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------