Provider Demographics
NPI:1710285010
Name:ABUNDANT CARE LLC
Entity Type:Organization
Organization Name:ABUNDANT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:YVETTE
Authorized Official - Last Name:MICKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-619-1169
Mailing Address - Street 1:5118 PARK AVE
Mailing Address - Street 2:SUITE 245
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117
Mailing Address - Country:US
Mailing Address - Phone:901-820-0701
Mailing Address - Fax:901-820-0709
Practice Address - Street 1:5118 PARK AVE
Practice Address - Street 2:SUITE 245
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117
Practice Address - Country:US
Practice Address - Phone:901-820-0701
Practice Address - Fax:901-820-0709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-10
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1000000008243253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH445529Medicaid