1679601280 NPI number — BOUNDLESS POTENTIAL, LLC

Table of content: (NPI 1679601280)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679601280 NPI number — BOUNDLESS POTENTIAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOUNDLESS POTENTIAL, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SISTER'S PLACE GROUP HOME II
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679601280
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 15238
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23227-0638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-290-0216
Provider Business Mailing Address Fax Number:
804-290-0427

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10204 SPINNING WHEEL WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-864-9001
Provider Business Practice Location Address Fax Number:
804-864-9002
Provider Enumeration Date:
03/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RALPH
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
MALONE
Authorized Official Title or Position:
DIRECTOR OF CLINICAL SERVICES
Authorized Official Telephone Number:
804-901-3122

Provider Taxonomy Codes

  • Taxonomy code: 322D00000X , with the licence number:  287-2006 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 008907757 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008907759 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00010231159 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com