Provider Demographics
NPI:1134471659
Name:ABUNDANT LIVING HEALTHCARE
Entity type:Organization
Organization Name:ABUNDANT LIVING HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:CAMILLE
Authorized Official - Last Name:DANCY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:662-347-9976
Mailing Address - Street 1:125 OLD MOUND BAYOU RD
Mailing Address - Street 2:
Mailing Address - City:MOUND BAYOU
Mailing Address - State:MS
Mailing Address - Zip Code:38762-9591
Mailing Address - Country:US
Mailing Address - Phone:662-741-3354
Mailing Address - Fax:
Practice Address - Street 1:202 GREEN ST
Practice Address - Street 2:
Practice Address - City:MOUND BAYOU
Practice Address - State:MS
Practice Address - Zip Code:38762-9762
Practice Address - Country:US
Practice Address - Phone:662-741-3354
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00530517376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00530517Medicaid