Healthcare Provider Details

I. General information

NPI: 1770808446
Provider Name (Legal Business Name): ABODE CARE PARTNERS AL VB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2010
Last Update Date: 12/26/2023
Certification Date: 12/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21412 GREAT MILLS RD
LEXINGTON PK MD
20653-1203
US

IV. Provider business mailing address

12201 BLUEGRASS PKWY
LOUISVILLE KY
40299-2361
US

V. Phone/Fax

Practice location:
  • Phone: 301-863-7244
  • Fax: 301-863-8550
Mailing address:
  • Phone: 502-568-7896
  • Fax: 502-568-7136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ANGIE MATTINGLY
Title or Position: MGR PROVIDER ENROLLMENT
Credential:
Phone: 502-394-2100