Provider Demographics
NPI:1336529080
Name:ABUNDANT LIFE NURSING AND SUPPORTIVE SERVICES LLC
Entity Type:Organization
Organization Name:ABUNDANT LIFE NURSING AND SUPPORTIVE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:FRAN
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-459-1245
Mailing Address - Street 1:1617 E ALFRED ST
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-3535
Mailing Address - Country:US
Mailing Address - Phone:352-459-1245
Mailing Address - Fax:
Practice Address - Street 1:1617 E ALFRED ST
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-3535
Practice Address - Country:US
Practice Address - Phone:352-459-1245
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9281220251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008118000Medicaid