MEDICARE: XTREM HEALTHCARE, 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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1730941873
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	XTREM HEALTHCARE, LLC

Provider Business Mailing Address
First Line	:	12203 TAYLORS WAY
Second Line	:
City	:	PICKERINGTON
State	:	OH
Zip	:	43147-9964
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12203 TAYLORS WAY
Second Line	:
City	:	PICKERINGTON
State	:	OH
Zip	:	43147-9964
Country	:	US
Telephone Number	:	651-399-8610
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	SOLANGE VALERIE L FONKEM
Credential	:
Telephone Number	:	615-399-8610

Provider Enumeration Date	:	01/24/2024
Last Update Date	:	01/24/2024

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