Healthcare Provider Details

I. General information

NPI: 1326857210
Provider Name (Legal Business Name): XTRAORDINARY HEALTH HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2025
Last Update Date: 01/06/2025
Certification Date: 01/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3521 STATE ST UNIT 4
SAGINAW MI
48602-3267
US

IV. Provider business mailing address

3521 STATE ST UNIT 4
SAGINAW MI
48602-3267
US

V. Phone/Fax

Practice location:
  • Phone: 989-280-6815
  • Fax:
Mailing address:
  • Phone:
  • 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: SHANIQUA SHA'NA LONG
Title or Position: CEO
Credential: LPN
Phone: 989-280-6815