Healthcare Provider Details

I. General information

NPI: 1376260190
Provider Name (Legal Business Name): XTREME NATURAL BODY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 03/21/2023
Certification Date: 02/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 PARK AVE STE 6
ORANGE PARK FL
32073-3109
US

IV. Provider business mailing address

534 PARK AVE STE 6
ORANGE PARK FL
32073-3109
US

V. Phone/Fax

Practice location:
  • Phone: 443-846-9100
  • Fax:
Mailing address:
  • Phone: 904-999-1363
  • Fax: 904-966-4006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. YVONNE MARIE GOOD
Title or Position: APRN / OWNER
Credential: APRN
Phone: 443-846-9100