Provider Demographics
NPI:1194886143
Name:ABUNDANT LIFE HOME LIFE, INC
Entity type:Organization
Organization Name:ABUNDANT LIFE HOME LIFE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:
Authorized Official - Last Name:DAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-536-2409
Mailing Address - Street 1:1505 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WELDON
Mailing Address - State:NC
Mailing Address - Zip Code:27890-2025
Mailing Address - Country:US
Mailing Address - Phone:252-536-2409
Mailing Address - Fax:252-536-5532
Practice Address - Street 1:1505 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:WELDON
Practice Address - State:NC
Practice Address - Zip Code:27890-2025
Practice Address - Country:US
Practice Address - Phone:252-536-2409
Practice Address - Fax:252-536-5532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601554Medicaid