Provider Demographics
NPI:1164675815
Name:OUTWARD BOUND ONE, LLC
Entity Type:Organization
Organization Name:OUTWARD BOUND ONE, LLC
Other - Org Name:OUTWARD BOUND COMMUNITY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRISHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:PATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-553-9898
Mailing Address - Street 1:620 GUILFORD COLLEGE RD
Mailing Address - Street 2:STE G
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27409-2292
Mailing Address - Country:US
Mailing Address - Phone:336-553-9898
Mailing Address - Fax:336-447-1955
Practice Address - Street 1:620 GUILFORD COLLEGE RD
Practice Address - Street 2:STE G
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27409-2292
Practice Address - Country:US
Practice Address - Phone:336-553-9898
Practice Address - Fax:336-447-1955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251S00000X
253Z00000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive Care