Provider Demographics
NPI:1376295774
Name:XTRORDINARY HEALTHCARE LLC
Entity Type:Organization
Organization Name:XTRORDINARY HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VANITA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCCLENDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-728-2209
Mailing Address - Street 1:3940 PALM STREET
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63107
Mailing Address - Country:US
Mailing Address - Phone:314-728-2209
Mailing Address - Fax:
Practice Address - Street 1:2610 N 14TH STREET
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63106
Practice Address - Country:US
Practice Address - Phone:314-728-2209
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health