MEDICARE: EXTENDED OUTREACH LIVING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376J00000X	Homemaker
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1407425390
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXTENDED OUTREACH LIVING LLC

Provider Business Mailing Address
First Line	:	6709 MARIOSA ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77028-5007
Country	:	US
Telephone Number	:	832-573-1435
Fax Number	:

Provider Business Practice Location Address
First Line	:	6709 MARIOSA ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77028-5007
Country	:	US
Telephone Number	:	832-573-1435
Fax Number	:

Authorized Official
Title or Position	:	CO-OWNER
Name	:	MS. KELSEA S THOMAS
Credential	:
Telephone Number	:	832-573-1435

Provider Enumeration Date	:	06/23/2021
Last Update Date	:	10/18/2021

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Directions to “EXTENDED OUTREACH LIVING LLC ” Practice Location

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