Provider Demographics
NPI:1598037426
Name:ABUNDANT LIFE ASSISTED SERAVICES INC
Entity type:Organization
Organization Name:ABUNDANT LIFE ASSISTED SERAVICES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:M
Authorized Official - Last Name:AIDOO
Authorized Official - Suffix:I
Authorized Official - Credentials:CNA
Authorized Official - Phone:678-319-0307
Mailing Address - Street 1:10800 ALPHARETTA HWY
Mailing Address - Street 2:SUITE 208- 713
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4621
Mailing Address - Country:US
Mailing Address - Phone:678-319-0307
Mailing Address - Fax:678-319-0307
Practice Address - Street 1:10800 ALPHARETTA HWY
Practice Address - Street 2:SUITE 208- 713
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1490
Practice Address - Country:US
Practice Address - Phone:678-319-0307
Practice Address - Fax:678-319-0307
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:N/A
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060-R-0501311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA744Medicaid