Healthcare Provider Details

I. General information

NPI: 1679154249
Provider Name (Legal Business Name): XTENDED HANDS HOMECARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2021
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W GLENDALE AVE APT 2091
PHOENIX AZ
85021-8809
US

IV. Provider business mailing address

1725 W GLENDALE AVE APT 2091
PHOENIX AZ
85021-8809
US

V. Phone/Fax

Practice location:
  • Phone: 623-387-0770
  • Fax:
Mailing address:
  • Phone: 623-387-0770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: LORNA RENEE JACKSON
Title or Position: OWNER
Credential: CNA
Phone: 623-387-0770