MEDICARE: ABUNDANT LIFE HEALTH SUPPORT

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	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1992544381
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABUNDANT LIFE HEALTH SUPPORT

Provider Business Mailing Address
First Line	:	3508 PINKHAM WAY
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27616-8322
Country	:	US
Telephone Number	:	952-737-3202
Fax Number	:

Provider Business Practice Location Address
First Line	:	3508 PINKHAM WAY
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27616-8322
Country	:	US
Telephone Number	:	952-737-3202
Fax Number	:	919-229-9577

Authorized Official
Title or Position	:	PMHNP
Name	:	MARTHA KERUBO OCHAKO
Credential	:	NP
Telephone Number	:	952-737-3202

Provider Enumeration Date	:	05/23/2024
Last Update Date	:	05/23/2024

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