Provider Demographics
NPI:1013134782
Name:ABUNDANT LIFE CHIROPRACTIC HEALTH CENTRE, INC.
Entity Type:Organization
Organization Name:ABUNDANT LIFE CHIROPRACTIC HEALTH CENTRE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LONIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:810-715-1225
Mailing Address - Street 1:3910 CHARLEMAGNE WAY SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-1587
Mailing Address - Country:US
Mailing Address - Phone:770-424-0453
Mailing Address - Fax:810-715-1245
Practice Address - Street 1:3910 CHARLEMAGNE WAY SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-1587
Practice Address - Country:US
Practice Address - Phone:770-424-0453
Practice Address - Fax:810-715-1245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007784111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2=========Medicaid
MIP43370Medicare PIN