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General NPI Number Information
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NPI Number | 1194456962
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Entity Type | Organization
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Legal Business Name | UNBOUND LIFE LLC
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Dates
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Enumeration Date | 06/22/2022
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Last Update Date | 01/10/2023
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Provider Practice Location Address
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Address Line | 100 PAR LN STE 102
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City | ELIZABETHTOWN
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State | KY
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Zip | 42701-9059
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Country | US
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Telephone | 270-506-3385
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Fax |
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Provider Business Mailing Address
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Address Line | 100 PAR LN STE 102
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City | ELIZABETHTOWN
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State | KY
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Zip | 42701-9059
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. CAMERON VANCE
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Credential |
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Telephone | 270-320-2605
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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