Provider Demographics
NPI:1073755336
Name:ABBTA INC
Entity Type:Organization
Organization Name:ABBTA INC
Other - Org Name:MT. VERNON AFC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ADEBIYI
Authorized Official - Middle Name:BILL
Authorized Official - Last Name:AINA
Authorized Official - Suffix:
Authorized Official - Credentials:LBSW
Authorized Official - Phone:269-267-7404
Mailing Address - Street 1:PO BOX 1391
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49081-1391
Mailing Address - Country:US
Mailing Address - Phone:269-342-5886
Mailing Address - Fax:
Practice Address - Street 1:5508 MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-1215
Practice Address - Country:US
Practice Address - Phone:269-342-5886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS390290297311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2097746Medicaid