Provider Demographics
NPI:1285076067
Name:ABUNDANT LIFE THERAPEUTIC SERVICES LLC
Entity type:Organization
Organization Name:ABUNDANT LIFE THERAPEUTIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-616-0657
Mailing Address - Street 1:645 CHURCH ST
Mailing Address - Street 2:SUITE 104C
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-1712
Mailing Address - Country:US
Mailing Address - Phone:757-616-0657
Mailing Address - Fax:757-533-9369
Practice Address - Street 1:645 CHURCH ST.
Practice Address - Street 2:SUITE 104C
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510
Practice Address - Country:US
Practice Address - Phone:757-616-0657
Practice Address - Fax:757-533-9369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-22
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2154320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities