1104153097 NPI number — ABUNDANT LIFE ENTERPRISES, LLC

Table of content: (NPI 1104153097)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104153097 NPI number — ABUNDANT LIFE ENTERPRISES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ABUNDANT LIFE ENTERPRISES, LLC
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:
A NEW CREATION WOMEN'S CLINIC
Provider Other Organization Name Type Code:
3
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:
1104153097
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3055 W. INA RD.
Provider Second Line Business Mailing Address:
#195
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85741-2136
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-293-1117
Provider Business Mailing Address Fax Number:
520-293-7701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3055 W INA RD
Provider Second Line Business Practice Location Address:
SUITE 195
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85741-2107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-293-1117
Provider Business Practice Location Address Fax Number:
520-293-7701
Provider Enumeration Date:
11/12/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CAMPBELL
Authorized Official First Name:
SHARON
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
520-293-1117

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Z79110 . This is a "MEDICARE - (A.L.E. - SC IND )" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 429971 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: Z79108 . This is a "MEDICARE GRP (A.L.E) -" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 192914 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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