MEDICARE: ABUNDANT LIFE CENTER II, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	895-14-00	VA

General Provider Information

NPI Number	:	1124191614
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABUNDANT LIFE CENTER II, LLC

Provider Business Mailing Address
First Line	:	1313 PLEASANT CREEK CT
Second Line	:
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-6841
Country	:	US
Telephone Number	:	804-651-7972
Fax Number	:	804-530-0195

Provider Business Practice Location Address
First Line	:	9831 KEVKEN DR
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23237-4058
Country	:	US
Telephone Number	:	804-748-3368
Fax Number	:	804-748-3662

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. RODNEY MARK WILLIAMS
Credential	:
Telephone Number	:	804-651-7972

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	08/22/2020

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