Basic Information
| Provider Information | |||||||||
| NPI: | 1861075707 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | I AM BOUNDLESS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 445 E DUBLIN GRANVILLE RD | ||||||||
| Address2: | |||||||||
| City: | WORTHINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430853192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148443800 | ||||||||
| FaxNumber: | 6145155779 | ||||||||
| Practice Location | |||||||||
| Address1: | 592 EVELYN AVE | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449071787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148443800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2021 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
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| AuthorizedOfficialLastName: | BARNER | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | REIMBURSEMENT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6148443800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | I AM BOUNDLESS, INC. | ||||||||
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| NPICertificationDate: | 04/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
No ID Information.