Provider Demographics
NPI:1891063947
Name:EXTRAORDINARY PRIVATE HOMECARE SERVICES LLC.
Entity Type:Organization
Organization Name:EXTRAORDINARY PRIVATE HOMECARE SERVICES LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:BRONCHELL
Authorized Official - Last Name:ISAAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-274-8787
Mailing Address - Street 1:PO BOX 1553
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31040-1553
Mailing Address - Country:US
Mailing Address - Phone:478-274-8787
Mailing Address - Fax:877-271-3257
Practice Address - Street 1:302 B-1 RAMSEY ST.
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021
Practice Address - Country:US
Practice Address - Phone:478-274-8787
Practice Address - Fax:877-271-3257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA087R0792251E00000X
GA087-R-0792332B00000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1891063947Medicaid