Provider Demographics
NPI:1336974914
Name:BOUNDLESS
Entity type:Organization
Organization Name:BOUNDLESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FAYOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ETIENNE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:862-371-8510
Mailing Address - Street 1:148 T ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-1579
Mailing Address - Country:US
Mailing Address - Phone:862-371-8510
Mailing Address - Fax:
Practice Address - Street 1:148 T ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-1579
Practice Address - Country:US
Practice Address - Phone:862-371-8510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy