Healthcare Provider Details

I. General information

NPI: 1003762014
Provider Name (Legal Business Name): ABUNDANT LIFE ASSISTED LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2026
Last Update Date: 03/10/2026
Certification Date: 03/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 W 75TH ST
LOS ANGELES CA
90044-2405
US

IV. Provider business mailing address

7252 ARCHIBALD AVE # 543
RANCHO CUCAMONGA CA
91701-5017
US

V. Phone/Fax

Practice location:
  • Phone: 310-926-7574
  • Fax:
Mailing address:
  • Phone: 310-926-7574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: QUIANNA STREET
Title or Position: LICENSEE
Credential:
Phone: 310-696-9555