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General NPI Number Information
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NPI Number | 1730719808
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Entity Type | Organization
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Legal Business Name | ABUNDANCE OF LIFE ADULT FAMILY HOME, LLC
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Dates
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Enumeration Date | 01/17/2020
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Last Update Date | 01/17/2020
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Provider Practice Location Address
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Address Line | 2355 HIGHWAY 36 W STE 431
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City | ROSEVILLE
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State | MN
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Zip | 55113-3902
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Country | US
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Telephone | 651-251-7100
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Fax |
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Provider Business Mailing Address
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Address Line | 2355 HIGHWAY 36 W STE 431
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City | ROSEVILLE
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State | MN
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Zip | 55113-3902
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Country | US
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Telephone | 651-251-7100
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR IN TRAINING
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Name | DR. MAHAD IBRAHIM
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Credential | PHD
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Telephone | 651-251-7100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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