Provider Demographics
NPI:1073890232
Name:ABUNDANT CARE IV
Entity Type:Organization
Organization Name:ABUNDANT CARE IV
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:PRYKO
Authorized Official - Suffix:
Authorized Official - Credentials:LVN
Authorized Official - Phone:805-845-1608
Mailing Address - Street 1:5421 BERKELEY RD
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93111-1613
Mailing Address - Country:US
Mailing Address - Phone:805-845-1608
Mailing Address - Fax:805-845-1609
Practice Address - Street 1:5421 BERKELEY RD
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93111-1613
Practice Address - Country:US
Practice Address - Phone:805-845-1608
Practice Address - Fax:805-845-1609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA425801755310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility