Provider Demographics
NPI:1457086654
Name:EXTREME INFUSED MEDICAL PLUS
Entity Type:Organization
Organization Name:EXTREME INFUSED MEDICAL PLUS
Other - Org Name:COAST TO COAST FAMILY WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:NIKALINA
Authorized Official - Middle Name:LELIEA
Authorized Official - Last Name:DUNDAS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN FNP C
Authorized Official - Phone:352-220-3873
Mailing Address - Street 1:11871 ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:DUNNELLON
Mailing Address - State:FL
Mailing Address - Zip Code:34431-6503
Mailing Address - Country:US
Mailing Address - Phone:352-220-3873
Mailing Address - Fax:352-517-7088
Practice Address - Street 1:11871 ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:DUNNELLON
Practice Address - State:FL
Practice Address - Zip Code:34431-6503
Practice Address - Country:US
Practice Address - Phone:352-220-3873
Practice Address - Fax:352-517-7088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-21
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No251F00000XAgenciesHome InfusionGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHUR18OtherBCBS