Provider Demographics
NPI:1033937156
Name:I AM BOUNDLESS, INC.
Entity type:Organization
Organization Name:I AM BOUNDLESS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING & CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-844-3800
Mailing Address - Street 1:445 E DUBLIN GRANVILLE RD STE H
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-3192
Mailing Address - Country:US
Mailing Address - Phone:614-844-3800
Mailing Address - Fax:
Practice Address - Street 1:445 E DUBLIN GRANVILLE RD STE H
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-3192
Practice Address - Country:US
Practice Address - Phone:614-844-3800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:I AM BOUNDLESS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty