Provider Demographics
NPI:1114524527
Name:ABUNDANT LIFE IN-HOME SERVICES, INC.
Entity Type:Organization
Organization Name:ABUNDANT LIFE IN-HOME SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAKESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:NANCE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:704-649-9904
Mailing Address - Street 1:10119 FIELDSTONE CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-2007
Mailing Address - Country:US
Mailing Address - Phone:704-649-9904
Mailing Address - Fax:
Practice Address - Street 1:301 MCCULLOUGH DR STE 400
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-1336
Practice Address - Country:US
Practice Address - Phone:704-649-9904
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-08
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCHC5727OtherDIVISION OF HEALTH SERVICE REGULATION