Healthcare Provider Details

I. General information

NPI: 1164245304
Provider Name (Legal Business Name): BLISSFUL JACKSON FACILITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2024
Last Update Date: 11/09/2024
Certification Date: 11/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4105 JACKSON ST
RIVERSIDE CA
92503-3911
US

IV. Provider business mailing address

4105 JACKSON ST
RIVERSIDE CA
92503-3911
US

V. Phone/Fax

Practice location:
  • Phone: 310-729-3844
  • Fax:
Mailing address:
  • Phone: 310-729-3844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: KEN CLAVIO
Title or Position: CEO
Credential:
Phone: 310-729-3844