Provider Demographics
NPI:1104153097
Name:ABUNDANT LIFE ENTERPRISES, LLC
Entity type:Organization
Organization Name:ABUNDANT LIFE ENTERPRISES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:R
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:WHNP-C
Authorized Official - Phone:520-293-1117
Mailing Address - Street 1:3055 W. INA RD.
Mailing Address - Street 2:#195
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-2136
Mailing Address - Country:US
Mailing Address - Phone:520-293-1117
Mailing Address - Fax:520-293-7701
Practice Address - Street 1:3055 W INA RD
Practice Address - Street 2:SUITE 195
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-2107
Practice Address - Country:US
Practice Address - Phone:520-293-1117
Practice Address - Fax:520-293-7701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-12
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ79110OtherMEDICARE - (A.L.E. - SC IND )
AZ429971Medicaid
AZZ79108OtherMEDICARE GRP (A.L.E) -
AZ192914Medicaid
AZ429971Medicaid