Provider Demographics
NPI:1881252385
Name:XTRACOMFORT HOME HEALTH AGENCY, LLC
Entity type:Organization
Organization Name:XTRACOMFORT HOME HEALTH AGENCY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ADEREMI
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, BSN, RN
Authorized Official - Phone:816-328-9304
Mailing Address - Street 1:6311 EVANSTON AVE STE A
Mailing Address - Street 2:
Mailing Address - City:RAYTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:64133-4929
Mailing Address - Country:US
Mailing Address - Phone:816-328-9304
Mailing Address - Fax:
Practice Address - Street 1:6311 EVANSTON AVE STE A
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64133-4929
Practice Address - Country:US
Practice Address - Phone:816-328-9304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-31
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
No163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1700253150Medicaid
MO1952727273Medicaid