Provider Demographics
NPI:1912292129
Name:ABUNDANT LIFE RESIDENTIAL SERVICES
Entity Type:Organization
Organization Name:ABUNDANT LIFE RESIDENTIAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LATONYA
Authorized Official - Middle Name:PATRICE
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-498-4557
Mailing Address - Street 1:8000 PRINCE GEORGES DR
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-2264
Mailing Address - Country:US
Mailing Address - Phone:202-498-4557
Mailing Address - Fax:
Practice Address - Street 1:8000 PRINCE GEORGES DR
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-2264
Practice Address - Country:US
Practice Address - Phone:202-498-4557
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC035966800Medicaid