Healthcare Provider Details

I. General information

NPI: 1215645833
Provider Name (Legal Business Name): XTRAORDINARY SPOT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 11/14/2022
Certification Date: 11/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4372 ALMATERRA DR
PERRIS CA
92571-5112
US

IV. Provider business mailing address

124 PINE CT
PERRIS CA
92571-2673
US

V. Phone/Fax

Practice location:
  • Phone: 562-235-7456
  • Fax:
Mailing address:
  • Phone: 909-997-8496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: SARDE STEWART
Title or Position: CLINICAL DIRECTOR
Credential: MS BCBA
Phone: 909-997-8496