Healthcare Provider Details

I. General information

NPI: 1801838461
Provider Name (Legal Business Name): ABUNDANT LIFE HCS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 HOUSTON ST N
MOUNT VERNON TX
75457-2409
US

IV. Provider business mailing address

PO BOX 461
MOUNT VERNON TX
75457-0461
US

V. Phone/Fax

Practice location:
  • Phone: 903-537-7404
  • Fax: 903-537-4406
Mailing address:
  • Phone: 903-537-7404
  • Fax: 903-537-4406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. MACK G. JONES
Title or Position: PROGRAM MANAGER
Credential:
Phone: 903-537-7404