Provider Demographics
NPI:1902491178
Name:ABUNDANT CHRISTIAN LIVING COMMUNITY LLC
Entity Type:Organization
Organization Name:ABUNDANT CHRISTIAN LIVING COMMUNITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-975-5455
Mailing Address - Street 1:2020 NORTHPARK DR STE 2D
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-3127
Mailing Address - Country:US
Mailing Address - Phone:423-975-5455
Mailing Address - Fax:423-390-0743
Practice Address - Street 1:2012 SHERWOOD DR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-3238
Practice Address - Country:US
Practice Address - Phone:423-232-8200
Practice Address - Fax:423-232-8240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-09
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility