MEDICARE: ABUNDANT LIFE HOME LIFE, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194886143
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABUNDANT LIFE HOME LIFE, INC

Provider Business Mailing Address
First Line	:	1505 WASHINGTON AVE
Second Line	:
City	:	WELDON
State	:	NC
Zip	:	27890-2025
Country	:	US
Telephone Number	:	252-536-2409
Fax Number	:	252-536-5532

Provider Business Practice Location Address
First Line	:	1505 WASHINGTON AVE
Second Line	:
City	:	WELDON
State	:	NC
Zip	:	27890-2025
Country	:	US
Telephone Number	:	252-536-2409
Fax Number	:	252-536-5532

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. RALPH DAILEY
Credential	:
Telephone Number	:	252-536-2409

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	08/22/2020

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