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General NPI Number Information
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NPI Number | 1891063947
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Entity Type | Organization
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Legal Business Name | EXTRAORDINARY PRIVATE HOMECARE SERVICES LLC.
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Dates
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Enumeration Date | 12/05/2011
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Last Update Date | 03/05/2012
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Provider Practice Location Address
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Address Line | 302 B-1 RAMSEY ST.
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City | DUBLIN
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State | GA
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Zip | 31021
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Country | US
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Telephone | 478-274-8787
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Fax | 877-271-3257
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Provider Business Mailing Address
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Address Line | PO BOX 1553
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City | DUBLIN
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State | GA
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Zip | 31040-1553
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Country | US
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Telephone | 478-274-8787
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Fax | 877-271-3257
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Authorized Official
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Title or Position | OWNER
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Name | THERESA BRONCHELL ISAAC
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Credential |
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Telephone | 478-274-8787
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 087-R-0792
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 385H00000X
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Taxonomy Name | Respite Care
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License Number | 087-R-0792
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 087R0792
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License Number State | GA
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