Provider Demographics
NPI:1609523604
Name:ABUNDANT LIFE HOME HEALTH AGENCY,LLC
Entity Type:Organization
Organization Name:ABUNDANT LIFE HOME HEALTH AGENCY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF NURSING
Authorized Official - Prefix:
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:
Authorized Official - Last Name:BRISSETT
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:727-286-8916
Mailing Address - Street 1:6601 MEMORIAL HWY STE 106
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-4501
Mailing Address - Country:US
Mailing Address - Phone:727-286-8916
Mailing Address - Fax:727-724-1201
Practice Address - Street 1:6601 MEMORIAL HWY STE 106
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-4501
Practice Address - Country:US
Practice Address - Phone:727-286-8916
Practice Address - Fax:727-724-1201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-09
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111860500Medicaid
FL299994461OtherAHCA LICENSE