Provider Demographics
NPI:1568810430
Name:ABUNDANT LIFE COMMUNITY DEVELOPMENT CORPORATION
Entity Type:Organization
Organization Name:ABUNDANT LIFE COMMUNITY DEVELOPMENT CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:FAGBAMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-983-6436
Mailing Address - Street 1:24 BLEVINS DR
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:DE
Mailing Address - Zip Code:19720-4152
Mailing Address - Country:US
Mailing Address - Phone:302-983-6436
Mailing Address - Fax:
Practice Address - Street 1:24 BLEVINS DR
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:DE
Practice Address - Zip Code:19720-4152
Practice Address - Country:US
Practice Address - Phone:302-983-6436
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-01
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Single Specialty
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Single Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled ServicesGroup - Single Specialty