=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790079077
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOUNDLESS HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2011
-----------------------------------------------------
Last Update Date | 06/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2929 N SOUTHPORT AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-6945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-566-8460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 516 N OGDEN AVE #203
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60642-6421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-562-0907
-----------------------------------------------------
Fax | 312-488-3651
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, PHYSICAL THERAPIST
-----------------------------------------------------
Name | JESSICA BRELJE
-----------------------------------------------------
Credential | MPT
-----------------------------------------------------
Telephone | 773-562-0907
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | 070013293
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------