Healthcare Provider Details

I. General information

NPI: 1821632415
Provider Name (Legal Business Name): XTREME PERSONAL CARE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2019
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 LAKE ST
EAST ORANGE NJ
07017-1704
US

IV. Provider business mailing address

16 LAKE ST
EAST ORANGE NJ
07017-1704
US

V. Phone/Fax

Practice location:
  • Phone: 862-285-6295
  • Fax:
Mailing address:
  • Phone: 862-285-6295
  • 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: SAMIYYAH M GIBSON
Title or Position: OWNER
Credential:
Phone: 862-285-6295