Provider Demographics
NPI:1639305774
Name:ABUNDANT LIFE HOME HEALTH CARE
Entity Type:Organization
Organization Name:ABUNDANT LIFE HOME HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-732-8391
Mailing Address - Street 1:6812 EWING AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-1882
Mailing Address - Country:US
Mailing Address - Phone:763-732-8391
Mailing Address - Fax:763-208-1975
Practice Address - Street 1:8633 EDINBROOK XING
Practice Address - Street 2:APT. 157
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-4017
Practice Address - Country:US
Practice Address - Phone:763-898-3492
Practice Address - Fax:763-898-3521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-03
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN343526251E00000X
MN344067251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health