Provider Demographics
NPI:1568857597
Name:ABUNDANT LIFE RESTORATION HEALTH CARE LLC
Entity Type:Organization
Organization Name:ABUNDANT LIFE RESTORATION HEALTH CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CORDELIA
Authorized Official - Middle Name:IFEYINWA
Authorized Official - Last Name:OKONKWO
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:443-985-6081
Mailing Address - Street 1:3517 LANGREHR RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21244-3067
Mailing Address - Country:US
Mailing Address - Phone:410-701-8814
Mailing Address - Fax:
Practice Address - Street 1:3517 LANGREHR RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21244-3067
Practice Address - Country:US
Practice Address - Phone:410-701-8814
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRS 3562253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care