=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104198068
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOUNDLESS HOME CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2012
-----------------------------------------------------
Last Update Date | 02/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 820 S POST RD STE B
-----------------------------------------------------
City | SHELBY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28152-6931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-406-9206
-----------------------------------------------------
Fax | 704-406-9857
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 820 S POST RD STE B
-----------------------------------------------------
City | SHELBY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28152-6931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-406-9206
-----------------------------------------------------
Fax | 704-406-9857
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AGENCY DIRECTOR
-----------------------------------------------------
Name | MRS. CYNTHIA ANN ROSS
-----------------------------------------------------
Credential | RN, BSN
-----------------------------------------------------
Telephone | 704-406-9206
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | HC4499
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------