Provider Demographics
NPI:1992544381
Name:ABUNDANT LIFE HEALTH SUPPORT
Entity type:Organization
Organization Name:ABUNDANT LIFE HEALTH SUPPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:KERUBO
Authorized Official - Last Name:OCHAKO
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:952-737-3202
Mailing Address - Street 1:3508 PINKHAM WAY
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-8322
Mailing Address - Country:US
Mailing Address - Phone:952-737-3202
Mailing Address - Fax:
Practice Address - Street 1:3508 PINKHAM WAY
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-8322
Practice Address - Country:US
Practice Address - Phone:952-737-3202
Practice Address - Fax:919-229-9577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty