Healthcare Provider Details

I. General information

NPI: 1942038278
Provider Name (Legal Business Name): BLISS EZIKE PSYCH TECH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2024
Last Update Date: 07/26/2024
Certification Date: 07/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 EDMONDS RD. BLDG. B
REDWOOD CA
94602
US

IV. Provider business mailing address

280 EDMONDS RD. BLDG. B
REDWOOD CA
94602
US

V. Phone/Fax

Practice location:
  • Phone: 408-529-0063
  • Fax:
Mailing address:
  • Phone: 408-529-0063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number36055
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: