Provider Demographics
NPI:1003288614
Name:ABUNDANT HEALTH MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:ABUNDANT HEALTH MEDICAL CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ADRIENNE
Authorized Official - Middle Name:CHANELLE
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-294-2758
Mailing Address - Street 1:PO BOX 5011
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70302-5011
Mailing Address - Country:US
Mailing Address - Phone:985-492-9111
Mailing Address - Fax:985-492-9114
Practice Address - Street 1:1001 JACKSON ST
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-3227
Practice Address - Country:US
Practice Address - Phone:985-492-9111
Practice Address - Fax:985-492-9114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2371231.Medicaid
LA2371231.Medicaid