Healthcare Provider Details

I. General information

NPI: 1912910688
Provider Name (Legal Business Name): ABUNDANT LIFE MEDICAL CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 01/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 N CHENEY ST
TAYLORVILLE IL
62568-2741
US

IV. Provider business mailing address

1141 N CHENEY ST
TAYLORVILLE IL
62568-2741
US

V. Phone/Fax

Practice location:
  • Phone: 217-824-2524
  • Fax: 217-824-2588
Mailing address:
  • Phone: 217-824-2524
  • Fax: 217-824-2588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number State

VIII. Authorized Official

Name: MISS GERRY A KLINEFELTER
Title or Position: OFFICE MANAGER
Credential:
Phone: 217-824-2524