1831653039 NPI number — ABUNDANT LIVING CARE ADULT FAMILY HOME

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831653039 NPI number — ABUNDANT LIVING CARE ADULT FAMILY HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ABUNDANT LIVING CARE ADULT FAMILY HOME
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831653039
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 18075
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53218-0075
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-403-9947
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2721 N 18TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53206-2135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-930-0138
Provider Business Practice Location Address Fax Number:
262-546-0749
Provider Enumeration Date:
01/22/2019

Additional Information

Authorized Official

Authorized Official Last Name:
BOHANON
Authorized Official First Name:
KIONDRA
Authorized Official Middle Name:
N
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
414-403-9947

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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