Provider Demographics
NPI:1770808446
Name:ABODE CARE PARTNERS AL VB, LLC
Entity type:Organization
Organization Name:ABODE CARE PARTNERS AL VB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTINGLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-394-2100
Mailing Address - Street 1:12201 BLUEGRASS PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-2361
Mailing Address - Country:US
Mailing Address - Phone:502-568-7896
Mailing Address - Fax:502-568-7136
Practice Address - Street 1:21412 GREAT MILLS RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON PK
Practice Address - State:MD
Practice Address - Zip Code:20653-1203
Practice Address - Country:US
Practice Address - Phone:301-863-7244
Practice Address - Fax:301-863-8550
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHC MEDICAL PARTNERS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-06
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD183055Medicare PIN