Provider Demographics
NPI:1629808092
Name:BOLD HORIZONS LLC
Entity type:Organization
Organization Name:BOLD HORIZONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARKITA
Authorized Official - Middle Name:
Authorized Official - Last Name:DISMUKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-503-8553
Mailing Address - Street 1:1818 HIGHWAY 134
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-6774
Mailing Address - Country:US
Mailing Address - Phone:318-503-8553
Mailing Address - Fax:800-613-4669
Practice Address - Street 1:1205 N 18TH ST STE 210
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5462
Practice Address - Country:US
Practice Address - Phone:318-503-8553
Practice Address - Fax:800-613-4669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-01
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility