=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972447357
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE PEAK LIFE RECOVERY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2026
-----------------------------------------------------
Last Update Date | 04/16/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 927 S LAFAYETTE ST
-----------------------------------------------------
City | SHELBY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28152-5851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-297-8211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 507 LEE DR
-----------------------------------------------------
City | SHELBY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28152-7615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AUTUMN JOY HARRIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-297-8211
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------