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General NPI Number Information
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NPI Number | 1952262016
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Entity Type | Organization
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Legal Business Name | BLOOMWELL MD MEDICAL CORPORATION
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Dates
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Enumeration Date | 11/19/2025
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Last Update Date | 11/19/2025
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Provider Practice Location Address
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Address Line | 333 SUNSET AVE STE 110A
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City | SUISUN CITY
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State | CA
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Zip | 94585-2003
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Country | US
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Telephone | 707-753-2388
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Fax |
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Provider Business Mailing Address
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Address Line | 333 SUNSET AVE STE 110A
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City | SUISUN CITY
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State | CA
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Zip | 94585-2003
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. KAOSOLUCHI ENENDU
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Credential | MD
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Telephone | 707-753-2388
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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