Healthcare Provider Details

I. General information

NPI: 1174759963
Provider Name (Legal Business Name): ABUNDANT LIFE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2009
Last Update Date: 04/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 MAIN ST
HARTFORD CT
06120-1936
US

IV. Provider business mailing address

PO BOX 714
HARTFORD CT
06142-0714
US

V. Phone/Fax

Practice location:
  • Phone: 860-548-9399
  • Fax:
Mailing address:
  • Phone: 860-548-9399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number104100000X
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number001806
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number001806
License Number StateCT

VIII. Authorized Official

Name: MR. TROY MOSES
Title or Position: CEO
Credential: PRESINDENT
Phone: 860-548-9399