Healthcare Provider Details

I. General information

NPI: 1033048160
Provider Name (Legal Business Name): EXTRAORDINARY HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 RYAN ST STE 400
LAKE CHARLES LA
70601-9405
US

IV. Provider business mailing address

1130 CAESARS CT
LAKE CHARLES LA
70611-6739
US

V. Phone/Fax

Practice location:
  • Phone: 337-377-8277
  • Fax:
Mailing address:
  • Phone: 337-377-8277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR LATASHA GRICE
Title or Position: OWNER
Credential: DNP,FNP-C, PMHNP-BC
Phone: 337-377-8277