=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083329643
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABUNDANCE OF LIFE, ADULT DAY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2023
-----------------------------------------------------
Last Update Date | 01/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6900 BOWMAN ROBERTS RD
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76179-3386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-363-9635
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 145 BIG SANDY LN
-----------------------------------------------------
City | LANCASTER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75146-2919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-363-9635
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | CHRISTINA REID
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-363-9635
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 373H00000X
-----------------------------------------------------
Taxonomy Name | Day Training/Habilitation Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------