MEDICARE: EXTENDED HEARTS HOME CARE 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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1710672688
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXTENDED HEARTS HOME CARE LLC

Provider Business Mailing Address
First Line	:	3417 EDGAR ST
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38127-5814
Country	:	US
Telephone Number	:	901-370-0525
Fax Number	:

Provider Business Practice Location Address
First Line	:	3417 EDGAR ST
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38127-5814
Country	:	US
Telephone Number	:	901-370-0525
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SHANICA NICOLE JOHNSON
Credential	:
Telephone Number	:	901-370-0525

Provider Enumeration Date	:	04/06/2023
Last Update Date	:	04/06/2023

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Directions to “EXTENDED HEARTS HOME CARE LLC ” Practice Location

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