1821517061 NPI number — ABUNDANCE OF LIFE INC

Table of content: (NPI 1821517061)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821517061 NPI number — ABUNDANCE OF LIFE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ABUNDANCE OF LIFE INC
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:
1821517061
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 101009
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:
53210-7009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-256-5000
Provider Business Mailing Address Fax Number:
844-274-3572

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2602 W SILVER SPRING DR
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53209-4292
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-256-5000
Provider Business Practice Location Address Fax Number:
844-274-3572
Provider Enumeration Date:
09/19/2017

Additional Information

Authorized Official

Authorized Official Last Name:
YOUNG
Authorized Official First Name:
NATALIA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
414-737-0708

Provider Taxonomy Codes

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

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

  • Identifier: 100058167 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com