=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922579986
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAMBI'S BLISS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2018
-----------------------------------------------------
Last Update Date | 12/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1060 N CAPITOL AVE STE E290
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46204-1081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-762-6058
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1946 N LINWOOD AVE
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46218-4572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-658-5677
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | AMBER DANIELLE NICOLE WILLS
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 317-658-5677
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------