Provider Demographics
NPI:1982840492
Name:ABUNDANT LIFE CARE SERVICES, LLC
Entity Type:Organization
Organization Name:ABUNDANT LIFE CARE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-682-2908
Mailing Address - Street 1:163 STRATFORD CT
Mailing Address - Street 2:BOX 26
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1836
Mailing Address - Country:US
Mailing Address - Phone:336-682-2908
Mailing Address - Fax:
Practice Address - Street 1:163 STRATFORD CT
Practice Address - Street 2:SUITE 236
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1836
Practice Address - Country:US
Practice Address - Phone:336-682-2908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-05
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health