Provider Demographics
NPI:1912910688
Name:ABUNDANT LIFE MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:ABUNDANT LIFE MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:GERRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:KLINEFELTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-824-2524
Mailing Address - Street 1:1141 N CHENEY ST
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-2741
Mailing Address - Country:US
Mailing Address - Phone:217-824-2524
Mailing Address - Fax:217-824-2588
Practice Address - Street 1:1141 N CHENEY ST
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-2741
Practice Address - Country:US
Practice Address - Phone:217-824-2524
Practice Address - Fax:217-824-2588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL952810Medicare PIN