Provider Demographics
NPI:1134746621
Name:ABUNDANT LIFE MEDICAL CLINIC
Entity type:Organization
Organization Name:ABUNDANT LIFE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:NABIL
Authorized Official - Last Name:TALLEUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-698-6206
Mailing Address - Street 1:34 RIVER POINTE WAY
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-0552
Mailing Address - Country:US
Mailing Address - Phone:805-698-6206
Mailing Address - Fax:
Practice Address - Street 1:338 E BETTERAVIA RD
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-7846
Practice Address - Country:US
Practice Address - Phone:805-698-6206
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty