Provider Demographics
NPI:1306323332
Name:ABUNDANT LOVE, LLC
Entity type:Organization
Organization Name:ABUNDANT LOVE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHAWANA
Authorized Official - Middle Name:ANTOINETTE
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-477-0424
Mailing Address - Street 1:10424 WALTON LAKE RD
Mailing Address - Street 2:
Mailing Address - City:DISPUTANTA
Mailing Address - State:VA
Mailing Address - Zip Code:23842-4703
Mailing Address - Country:US
Mailing Address - Phone:757-477-0424
Mailing Address - Fax:
Practice Address - Street 1:10424 WALTON LAKE RD
Practice Address - Street 2:
Practice Address - City:DISPUTANTA
Practice Address - State:VA
Practice Address - Zip Code:23842-4703
Practice Address - Country:US
Practice Address - Phone:757-477-0424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2452-01-001320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities