=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700425725
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOUNDLESS BREATH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2019
-----------------------------------------------------
Last Update Date | 02/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5281 LOWER KULA RD
-----------------------------------------------------
City | KULA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96790-7712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-458-5738
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5281 LOWER KULA RD
-----------------------------------------------------
City | KULA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96790-7712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-458-5738
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HEAVEN MARCULIS
-----------------------------------------------------
Credential | OTR/L
-----------------------------------------------------
Telephone | 727-458-5738
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0019X
-----------------------------------------------------
Taxonomy Name | Physical Rehabilitation Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------