MEDICARE: ABUNDANT LIFE RESIDENTIAL SERVICES

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	171W00000X	Contractor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912292129
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABUNDANT LIFE RESIDENTIAL SERVICES

Provider Business Mailing Address
First Line	:	8000 PRINCE GEORGES DR
Second Line	:
City	:	FORT WASHINGTON
State	:	MD
Zip	:	20744-2264
Country	:	US
Telephone Number	:	202-498-4557
Fax Number	:

Provider Business Practice Location Address
First Line	:	8000 PRINCE GEORGES DR
Second Line	:
City	:	FORT WASHINGTON
State	:	MD
Zip	:	20744-2264
Country	:	US
Telephone Number	:	202-498-4557
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	LATONYA PATRICE POWELL
Credential	:
Telephone Number	:	202-498-4557

Provider Enumeration Date	:	06/15/2011
Last Update Date	:	06/15/2011

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