MEDICARE: BLISS MANOR, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320800000X	Mental Illness Community Based Residential Treatment Facility	032706	MO

General Provider Information

NPI Number	:	1669525481
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLISS MANOR, INC.

Provider Business Mailing Address
First Line	:	PO BOX 7350
Second Line	:
City	:	SAINT JOSEPH
State	:	MO
Zip	:	64507-7350
Country	:	US
Telephone Number	:	816-279-0587
Fax Number	:	816-279-3461

Provider Business Practice Location Address
First Line	:	3919 MESSANIE ST
Second Line	:
City	:	SAINT JOSEPH
State	:	MO
Zip	:	64506-3458
Country	:	US
Telephone Number	:	816-233-4463
Fax Number	:	816-233-4463

Authorized Official
Title or Position	:	VICE-PRESIDENT
Name	:	MR. BRADLEY STEVEN WICKHAM
Credential	:
Telephone Number	:	816-279-0587

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	08/22/2020

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