Provider Demographics
NPI:1033828694
Name:BOUNDLESS NUTRITION LLC
Entity Type:Organization
Organization Name:BOUNDLESS NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:EACKLOFF
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:703-705-2720
Mailing Address - Street 1:13112 MOSS RANCH LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-3524
Mailing Address - Country:US
Mailing Address - Phone:703-705-2720
Mailing Address - Fax:
Practice Address - Street 1:13112 MOSS RANCH LN
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-3524
Practice Address - Country:US
Practice Address - Phone:703-705-2720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-22
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center