=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205076155
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABUNDANT LIFE HOME HEALTH AGENCY,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2009
-----------------------------------------------------
Last Update Date | 05/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6601 MEMORIAL HWY STE 106
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33615-4501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-286-8916
-----------------------------------------------------
Fax | 727-724-1201
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28050 US HIGHWAY 19 N STE 205
-----------------------------------------------------
City | CLEARWATER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33761-2627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-286-8916
-----------------------------------------------------
Fax | 727-724-1201
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF NURSING
-----------------------------------------------------
Name | TRACI S BRISSETT
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 727-286-8916
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 299993080
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------