=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306323332
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABUNDANT LOVE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2018
-----------------------------------------------------
Last Update Date | 07/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10424 WALTON LAKE RD
-----------------------------------------------------
City | DISPUTANTA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23842-4703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-477-0424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10424 WALTON LAKE RD
-----------------------------------------------------
City | DISPUTANTA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23842-4703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-477-0424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MS. SHAWANA ANTOINETTE ROACH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-477-0424
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | 2452-01-001
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------