MEDICARE: EXTREME CARE SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	311ZA0620X	Adult Care Home Facility	FL
2	261QH0100X	Health Service Clinic/Center	FL
3	253Z00000X	In Home Supportive Care Agency	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	39965537	OTHER	FL	AHCA NUMBER

General Provider Information

NPI Number	:	1881846418
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXTREME CARE SERVICES LLC

Provider Business Mailing Address
First Line	:	5604 TOWN N COUNTRY BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33615-4142
Country	:	US
Telephone Number	:	813-731-3250
Fax Number	:	313-731-3252

Provider Business Practice Location Address
First Line	:	5604 TOWN N COUNTRY BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33615-4142
Country	:	US
Telephone Number	:	813-731-3250
Fax Number	:	313-731-3252

Authorized Official
Title or Position	:	MGR
Name	:	MS. EVELYN AMANDA ROSARIO JACKSON
Credential	:
Telephone Number	:	813-731-3250

Provider Enumeration Date	:	10/14/2008
Last Update Date	:	09/09/2013

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Directions to “EXTREME CARE SERVICES LLC ” Practice Location

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