Provider Demographics
NPI:1093416273
Name:BLOOMWELL PEDIATRIC WELLNESS AND PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:BLOOMWELL PEDIATRIC WELLNESS AND PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:949-229-0170
Mailing Address - Street 1:25255 CABOT RD STE 112
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-5507
Mailing Address - Country:US
Mailing Address - Phone:949-229-0170
Mailing Address - Fax:
Practice Address - Street 1:25255 CABOT RD STE 112
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-5507
Practice Address - Country:US
Practice Address - Phone:949-229-0170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty