Healthcare Provider Details

I. General information

NPI: 1437974219
Provider Name (Legal Business Name): EXTOL HAVEN HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 AUBURN DR STE 200
BEACHWOOD OH
44122-4328
US

IV. Provider business mailing address

19412 GARDENVIEW DR
MAPLE HEIGHTS OH
44137-2342
US

V. Phone/Fax

Practice location:
  • Phone: 216-453-8855
  • Fax:
Mailing address:
  • Phone: 216-505-3187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: PRINCE C UGWU
Title or Position: OWNER
Credential:
Phone: 216-453-8991