Healthcare Provider Details

I. General information

NPI: 1134746621
Provider Name (Legal Business Name): ABUNDANT LIFE MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2020
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 E BETTERAVIA RD
SANTA MARIA CA
93454-7846
US

IV. Provider business mailing address

34 RIVER POINTE WAY
LODI CA
95240-0552
US

V. Phone/Fax

Practice location:
  • Phone: 805-698-6206
  • Fax:
Mailing address:
  • Phone: 805-698-6206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BRIAN NABIL TALLEUR
Title or Position: OWNER
Credential: MD
Phone: 805-698-6206