=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851835292
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABUNDANT LIFE CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2016
-----------------------------------------------------
Last Update Date | 12/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16823 NE 116TH ST
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64068-8278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-668-5586
-----------------------------------------------------
Fax | 816-453-9068
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16823 NE 116TH ST
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64068-8278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-668-5586
-----------------------------------------------------
Fax | 816-453-9068
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SOPHIA FISHER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 816-668-5586
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------