=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407063928
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ASSISTED LIVING CONCEPTS BLISS HOUSE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3008 S SHAWNEE DR
-----------------------------------------------------
City | BEDFORD
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47421-5282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-275-2468
-----------------------------------------------------
Fax | 812-275-2491
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3008 S SHAWNEE DR
-----------------------------------------------------
City | BEDFORD
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47421-5282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-275-2468
-----------------------------------------------------
Fax | 812-275-2491
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RESIDENCE DIRECTOR
-----------------------------------------------------
Name | MRS. SHOLIN JOELE MONTGOMERY
-----------------------------------------------------
Credential | HFA
-----------------------------------------------------
Telephone | 812-275-2468
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------