Provider Demographics
NPI:1164616835
Name:ABUNDANT LIVING GROUP HOME, INC
Entity Type:Organization
Organization Name:ABUNDANT LIVING GROUP HOME, INC
Other - Org Name:NEW ABUNDANT LIVING I
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:ANIECE
Authorized Official - Last Name:TIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-623-7669
Mailing Address - Street 1:438 CREEKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-2817
Mailing Address - Country:US
Mailing Address - Phone:336-623-7669
Mailing Address - Fax:336-623-1139
Practice Address - Street 1:438 CREEKRIDGE DR
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-2817
Practice Address - Country:US
Practice Address - Phone:336-623-7669
Practice Address - Fax:336-623-1139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-079-076322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children