MEDICARE: FUNCTION FOUNDATION, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT 26653	CA
2	225100000X	Physical Therapist	PT 24080	CA
3	225100000X	Physical Therapist	PT 26678	CA
4	2251P0200X	Pediatric Physical Therapist	PT 26678	CA
5	225100000X	Physical Therapist	PT 26571	CA

General Provider Information

NPI Number	:	1447405964
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FUNCTION FOUNDATION, INC.

Provider Business Mailing Address
First Line	:	3323 CARMEL MOUNTAIN RD
Second Line	:	SUITE 200
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-1035
Country	:	US
Telephone Number	:	858-720-0991
Fax Number	:	858-720-0992

Provider Business Practice Location Address
First Line	:	3323 CARMEL MOUNTAIN RD
Second Line	:	SUITE 200
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-1035
Country	:	US
Telephone Number	:	858-720-0991
Fax Number	:	858-720-0992

Authorized Official
Title or Position	:	CEO
Name	:	BRETT W BLOOM
Credential	:	DPT
Telephone Number	:	619-229-3909

Provider Enumeration Date	:	11/25/2008
Last Update Date	:	11/25/2008

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Directions to “FUNCTION FOUNDATION, INC. ” Practice Location

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