Provider Demographics
NPI:1417501040
Name:EXTRACARE & WELLNESS LLC
Entity Type:Organization
Organization Name:EXTRACARE & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KETTIA
Authorized Official - Middle Name:CADET
Authorized Official - Last Name:CHERENFANT
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:321-246-5358
Mailing Address - Street 1:1410 N PINE HILLS RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32808-4408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1410 N PINE HILLS RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32808-4408
Practice Address - Country:US
Practice Address - Phone:321-246-5358
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-31
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty