Provider Demographics
NPI:1164391330
Name:ABUNDANT LIFE SUPPORT SERVICES, LLC
Entity type:Organization
Organization Name:ABUNDANT LIFE SUPPORT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:C
Authorized Official - Last Name:SOTO
Authorized Official - Suffix:
Authorized Official - Credentials:LCAS-A
Authorized Official - Phone:704-771-5592
Mailing Address - Street 1:6416 REA RD STE B7
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-4346
Mailing Address - Country:US
Mailing Address - Phone:980-527-5600
Mailing Address - Fax:
Practice Address - Street 1:1193 JASMINE DR
Practice Address - Street 2:
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707-1504
Practice Address - Country:US
Practice Address - Phone:704-771-5592
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-11-04
Last Update Date:2025-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health