Provider Demographics
NPI:1184930463
Name:ABUNDANT LIFE CENTER IIH & MHSS
Entity type:Organization
Organization Name:ABUNDANT LIFE CENTER IIH & MHSS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:PRINCE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:804-399-7108
Mailing Address - Street 1:4222 BONNIEBANK RD #304
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23234
Mailing Address - Country:US
Mailing Address - Phone:804-399-7108
Mailing Address - Fax:804-293-0857
Practice Address - Street 1:4222 BONNIEBANK RD #304
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23234
Practice Address - Country:US
Practice Address - Phone:804-399-7108
Practice Address - Fax:804-293-0857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-25
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA895-03-001251S00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty