Provider Demographics
NPI:1346777653
Name:ABUNDANCE CARE, FAMILY PRACTICE CLINIC
Entity Type:Organization
Organization Name:ABUNDANCE CARE, FAMILY PRACTICE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER / OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JASCHANDRIA
Authorized Official - Middle Name:I
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:318-243-2411
Mailing Address - Street 1:PO BOX 5281
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71171-5281
Mailing Address - Country:US
Mailing Address - Phone:318-243-2411
Mailing Address - Fax:318-562-3309
Practice Address - Street 1:105 LANCASHIRE DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2022
Practice Address - Country:US
Practice Address - Phone:318-243-2411
Practice Address - Fax:318-562-3309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-17
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2404580Medicaid