Provider Demographics
NPI:1750627675
Name:XTRA HOMECARE SERVICES, INC.
Entity type:Organization
Organization Name:XTRA HOMECARE SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PEARL
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-527-0466
Mailing Address - Street 1:PO BOX 25249
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29616-0249
Mailing Address - Country:US
Mailing Address - Phone:864-527-0466
Mailing Address - Fax:864-288-9872
Practice Address - Street 1:33 MARKET POINT DR
Practice Address - Street 2:SUITE 2016
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5768
Practice Address - Country:US
Practice Address - Phone:864-527-0466
Practice Address - Fax:864-288-9872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-20
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCEX1162Medicaid