Provider Demographics
NPI:1992055073
Name:BLISS MYOFASCIAL RELEASE
Entity type:Organization
Organization Name:BLISS MYOFASCIAL RELEASE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:PUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:727-365-8838
Mailing Address - Street 1:800 TARPON WOODS BLVD
Mailing Address - Street 2:SUITE F1
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34685-2011
Mailing Address - Country:US
Mailing Address - Phone:727-365-8838
Mailing Address - Fax:
Practice Address - Street 1:800 TARPON WOODS BLVD STE F1
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34685-2000
Practice Address - Country:US
Practice Address - Phone:727-365-8838
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-14
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT23951225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty