Healthcare Provider Details

I. General information

NPI: 1386216570
Provider Name (Legal Business Name): XTRAORDINARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 IH 10 S STE 210
BEAUMONT TX
77707-4444
US

IV. Provider business mailing address

3910 TREADWAY RD APT 803
BEAUMONT TX
77706-7137
US

V. Phone/Fax

Practice location:
  • Phone: 409-433-7433
  • Fax:
Mailing address:
  • Phone: 409-433-7433
  • 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: MS. CLARISSA JOHNNIE
Title or Position: LVN
Credential:
Phone: 409-433-7433