1194326728 NPI number — BLISS LIFE RESIDENTIAL CARE

Table of content: DAVID M LYONS (NPI 1639533243)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194326728 NPI number — BLISS LIFE RESIDENTIAL CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLISS LIFE RESIDENTIAL CARE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194326728
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
402 ARTHUR AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEHIGH ACRES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33936-7412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-603-3734
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
402 ARTHUR AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEHIGH ACRES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33936-7412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-603-3734
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/02/2020

Additional Information

Authorized Official

Authorized Official Last Name:
JOSEPH
Authorized Official First Name:
VIERGELA
Authorized Official Middle Name:
DESHOMMES
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
239-603-3734

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 60243 . This is a "AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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