Healthcare Provider Details

I. General information

NPI: 1891063947
Provider Name (Legal Business Name): EXTRAORDINARY PRIVATE HOMECARE SERVICES LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2011
Last Update Date: 03/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 B-1 RAMSEY ST.
DUBLIN GA
31021
US

IV. Provider business mailing address

PO BOX 1553
DUBLIN GA
31040-1553
US

V. Phone/Fax

Practice location:
  • Phone: 478-274-8787
  • Fax: 877-271-3257
Mailing address:
  • Phone: 478-274-8787
  • Fax: 877-271-3257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number087-R-0792
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number087-R-0792
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number087R0792
License Number StateGA

VIII. Authorized Official

Name: THERESA BRONCHELL ISAAC
Title or Position: OWNER
Credential:
Phone: 478-274-8787