MEDICARE: ABUNDANCE HOME CARE SOURCE LLC

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	253Z00000X	In Home Supportive Care Agency
2	163W00000X	Registered Nurse

General Provider Information

NPI Number	:	1285371419
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABUNDANCE HOME CARE SOURCE LLC

Provider Business Mailing Address
First Line	:	154 RAINBOW WAY # 187
Second Line	:
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30214-3994
Country	:	US
Telephone Number	:	770-424-7700
Fax Number	:	470-691-1284

Provider Business Practice Location Address
First Line	:	115 WHITE RD
Second Line	:
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30214-1203
Country	:	US
Telephone Number	:	856-723-2227
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	FELICITA WRIGHT
Credential	:
Telephone Number	:	856-723-2227

Provider Enumeration Date	:	05/18/2022
Last Update Date	:	04/22/2024

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