Provider Demographics
NPI:1174031892
Name:ABUNDANT CARE CLINIC
Entity Type:Organization
Organization Name:ABUNDANT CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAULETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-964-0757
Mailing Address - Street 1:18702 RED MAPLE CT
Mailing Address - Street 2:
Mailing Address - City:TRIANGLE
Mailing Address - State:VA
Mailing Address - Zip Code:22172-1511
Mailing Address - Country:US
Mailing Address - Phone:202-487-7156
Mailing Address - Fax:
Practice Address - Street 1:18702 RED MAPLE CT
Practice Address - Street 2:
Practice Address - City:TRIANGLE
Practice Address - State:VA
Practice Address - Zip Code:22172-1511
Practice Address - Country:US
Practice Address - Phone:202-487-7156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service