Healthcare Provider Details

I. General information

NPI: 1104648963
Provider Name (Legal Business Name): EXTRAORDINARY HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2024
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 GREENWICH RD
CHARLOTTE NC
28211-2315
US

IV. Provider business mailing address

219 GREENWICH RD
CHARLOTTE NC
28211-2315
US

V. Phone/Fax

Practice location:
  • Phone: 704-879-2394
  • Fax: 704-220-2381
Mailing address:
  • Phone: 704-879-2394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. KENNETH J FLEMING
Title or Position: ADMINISTRATOR
Credential:
Phone: 704-879-2394