Provider Demographics
NPI:1831817758
Name:BLISS AESTHETICS MEDICAL SPA LLC
Entity type:Organization
Organization Name:BLISS AESTHETICS MEDICAL SPA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:575-318-1068
Mailing Address - Street 1:2919 N CLIFFWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:HOBBS
Mailing Address - State:NM
Mailing Address - Zip Code:88240-2573
Mailing Address - Country:US
Mailing Address - Phone:575-318-1068
Mailing Address - Fax:
Practice Address - Street 1:2919 N CLIFFWOOD CIR
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88240-2573
Practice Address - Country:US
Practice Address - Phone:575-318-1068
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLISS WOMEN'S HEALTH LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-16
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Yes2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity MedicineGroup - Single Specialty
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy