Healthcare Provider Details

I. General information

NPI: 1831332691
Provider Name (Legal Business Name): BOUNDLESS MIRACLES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2009
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S POST RD
SHELBY NC
28152-6931
US

IV. Provider business mailing address

820 S POST RD STE A
SHELBY NC
28152-6931
US

V. Phone/Fax

Practice location:
  • Phone: 704-406-9813
  • Fax: 704-406-9857
Mailing address:
  • Phone: 704-406-9813
  • Fax: 704-406-9857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. RONALD KEITH CHURCH
Title or Position: OWNER / CEO
Credential:
Phone: 704-692-4700