Healthcare Provider Details

I. General information

NPI: 1629808092
Provider Name (Legal Business Name): BOLD HORIZONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 N 18TH ST STE 210
MONROE LA
71201-5462
US

IV. Provider business mailing address

1818 HIGHWAY 134
MONROE LA
71203-6774
US

V. Phone/Fax

Practice location:
  • Phone: 318-503-8553
  • Fax: 800-613-4669
Mailing address:
  • Phone: 318-503-8553
  • Fax: 800-613-4669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARKITA DISMUKE
Title or Position: OWNER/MANAGER
Credential:
Phone: 318-503-8553