Provider Demographics
NPI:1831653039
Name:ABUNDANT LIVING CARE ADULT FAMILY HOME
Entity Type:Organization
Organization Name:ABUNDANT LIVING CARE ADULT FAMILY HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KIONDRA
Authorized Official - Middle Name:N
Authorized Official - Last Name:BOHANON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-403-9947
Mailing Address - Street 1:PO BOX 18075
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-0075
Mailing Address - Country:US
Mailing Address - Phone:414-403-9947
Mailing Address - Fax:
Practice Address - Street 1:2721 N 18TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53206-2135
Practice Address - Country:US
Practice Address - Phone:414-930-0138
Practice Address - Fax:262-546-0749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health