Provider Demographics
NPI:1982182150
Name:ABUNDANT GRACE HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:ABUNDANT GRACE HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:SANJA
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE
Authorized Official - Phone:240-468-6009
Mailing Address - Street 1:4645 NANNIE HELEN BURROUGHS AVE NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20019-3622
Mailing Address - Country:US
Mailing Address - Phone:240-468-6009
Mailing Address - Fax:
Practice Address - Street 1:4645 NANNIE HELEN BURROUGHS AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-3622
Practice Address - Country:US
Practice Address - Phone:240-468-6009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC012218-388251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health