Healthcare Provider Details

I. General information

NPI: 1982180113
Provider Name (Legal Business Name): ABUNDANT HEALTHCARE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 SERRAL DR
GREENEVILLE TN
37745-3074
US

IV. Provider business mailing address

2101 HIGHWAY 80
HAUGHTON LA
71037-9488
US

V. Phone/Fax

Practice location:
  • Phone: 423-638-7499
  • Fax:
Mailing address:
  • Phone: 318-949-5515
  • Fax: 318-949-5555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MERLON KENT CRAFT
Title or Position: EVP/CFO
Credential:
Phone: 318-949-5515