Provider Demographics
NPI:1255973210
Name:BLISSFULLY SUPPORTED LLC
Entity type:Organization
Organization Name:BLISSFULLY SUPPORTED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ARTEECA
Authorized Official - Middle Name:
Authorized Official - Last Name:ECCLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:980-474-9219
Mailing Address - Street 1:645 DUNBROOK LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-3405
Mailing Address - Country:US
Mailing Address - Phone:980-474-9219
Mailing Address - Fax:
Practice Address - Street 1:645 DUNBROOK LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-3405
Practice Address - Country:US
Practice Address - Phone:980-474-9219
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility