Provider Demographics
NPI:1215167754
Name:C&M ABUNDANT GRACE, LLC
Entity type:Organization
Organization Name:C&M ABUNDANT GRACE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:HCA
Authorized Official - Phone:918-289-0000
Mailing Address - Street 1:9717 E 42ND ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-3618
Mailing Address - Country:US
Mailing Address - Phone:918-289-0000
Mailing Address - Fax:918-289-0202
Practice Address - Street 1:9717 E 42ND ST
Practice Address - Street 2:SUITE 101
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-3618
Practice Address - Country:US
Practice Address - Phone:918-289-0000
Practice Address - Fax:918-289-0202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-17
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7886253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care