Provider Demographics
NPI:1518010131
Name:BLISS MANOR, INC.
Entity Type:Organization
Organization Name:BLISS MANOR, INC.
Other - Org Name:EASTGATE MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:WICKHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-279-0587
Mailing Address - Street 1:PO BOX 7350
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64507-7350
Mailing Address - Country:US
Mailing Address - Phone:816-279-0587
Mailing Address - Fax:816-279-3461
Practice Address - Street 1:2102 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-4983
Practice Address - Country:US
Practice Address - Phone:816-233-2141
Practice Address - Fax:816-233-2141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031734320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness