Provider Demographics
NPI:1376260190
Name:XTREME NATURAL BODY
Entity Type:Organization
Organization Name:XTREME NATURAL BODY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN / OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GOOD
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:443-846-9100
Mailing Address - Street 1:534 PARK AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-3109
Mailing Address - Country:US
Mailing Address - Phone:904-999-1363
Mailing Address - Fax:904-966-4006
Practice Address - Street 1:534 PARK AVE STE 6
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-3109
Practice Address - Country:US
Practice Address - Phone:443-846-9100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-24
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1316240716Medicaid
FL9432176OtherLICENSE NUMBER