Provider Demographics
NPI:1043739139
Name:EXTENDED HEARTS LLC
Entity Type:Organization
Organization Name:EXTENDED HEARTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-287-7472
Mailing Address - Street 1:55 BECKLEY FARM WAY
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-7508
Mailing Address - Country:US
Mailing Address - Phone:947-287-7472
Mailing Address - Fax:
Practice Address - Street 1:722 BLACKMOAT PL
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-2725
Practice Address - Country:US
Practice Address - Phone:937-287-7472
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-11
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 251J00000X, 251S00000X, 253J00000X, 253Z00000X, 3104A0625X, 3104A0630X, 313M00000X, 385H00000X
OH310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
No251S00000XAgenciesCommunity/Behavioral Health
No253J00000XAgenciesFoster Care Agency
No253Z00000XAgenciesIn Home Supportive Care
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0196030Medicaid