Provider Demographics
NPI:1164814240
Name:ABUNDANT LIVING CONSUMER DIRECTED SERVICES LLC
Entity type:Organization
Organization Name:ABUNDANT LIVING CONSUMER DIRECTED SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-951-4042
Mailing Address - Street 1:2730 VALLEY BROOK DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-1985
Mailing Address - Country:US
Mailing Address - Phone:314-265-0373
Mailing Address - Fax:314-830-1601
Practice Address - Street 1:2730 VALLEY BROOK DR
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-1985
Practice Address - Country:US
Practice Address - Phone:314-265-0373
Practice Address - Fax:314-830-1601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-25
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC001419437251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health