1639305774 NPI number — ABUNDANT LIFE HOME HEALTH CARE

Table of content: (NPI 1639305774)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639305774 NPI number — ABUNDANT LIFE HOME HEALTH CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ABUNDANT LIFE HOME HEALTH CARE
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:
1639305774
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6812 EWING AVE N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN CENTER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55429-1882
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-732-8391
Provider Business Mailing Address Fax Number:
763-208-1975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5901 BROOKLYN BLVD.
Provider Second Line Business Practice Location Address:
STE 110
Provider Business Practice Location Address City Name:
BROOKLYN CENTER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55429-4017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-843-0735
Provider Business Practice Location Address Fax Number:
763-777-8727
Provider Enumeration Date:
06/03/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MARSHALL
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
THOMAS
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
763-843-0735

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  343526 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X , with the licence number: 344067 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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