Healthcare Provider Details

I. General information

NPI: 1831653039
Provider Name (Legal Business Name): ABUNDANT LIVING CARE ADULT FAMILY HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2019
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2721 N 18TH ST
MILWAUKEE WI
53206-2135
US

IV. Provider business mailing address

PO BOX 18075
MILWAUKEE WI
53218-0075
US

V. Phone/Fax

Practice location:
  • Phone: 262-478-0737
  • Fax: 262-546-0749
Mailing address:
  • Phone: 414-403-9947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. KIONDRA N BOHANON
Title or Position: ADMINISTRATOR
Credential:
Phone: 414-403-9947