MEDICARE: ABUNDANT GRACE 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1316644636
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABUNDANT GRACE LLC

Provider Business Mailing Address
First Line	:	P.O. BOX 5693
Second Line	:
City	:	GOODYEAR
State	:	AZ
Zip	:	85338
Country	:	US
Telephone Number	:	623-521-5935
Fax Number	:	602-441-4838

Provider Business Practice Location Address
First Line	:	7227 S CENTRAL AVE
Second Line	:	#1080
City	:	PHOENIX
State	:	AZ
Zip	:	85042-2951
Country	:	US
Telephone Number	:	623-521-5935
Fax Number	:	602-441-4838

Authorized Official
Title or Position	:	OWNER
Name	:	OLUFEMI OMODARA
Credential	:	RPH
Telephone Number	:	623-521-5935

Provider Enumeration Date	:	02/08/2023
Last Update Date	:	02/08/2023

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