Provider Demographics
NPI:1235325275
Name:ABUNDANT LIFE COMMUNITY OUTREACH, INC.
Entity Type:Organization
Organization Name:ABUNDANT LIFE COMMUNITY OUTREACH, INC.
Other - Org Name:ALCO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GUION
Authorized Official - Suffix:
Authorized Official - Credentials:BPSYC
Authorized Official - Phone:910-455-4572
Mailing Address - Street 1:1508 GUM BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-5216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1508 GUM BRANCH RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-5216
Practice Address - Country:US
Practice Address - Phone:910-455-4572
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8700368Medicaid