Provider Demographics
NPI:1699440214
Name:XTRA CARE CLINIC LLC
Entity type:Organization
Organization Name:XTRA CARE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EVELYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:IMAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-365-0084
Mailing Address - Street 1:5700 SAINT THOMAS DR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75094-4620
Mailing Address - Country:US
Mailing Address - Phone:972-365-0084
Mailing Address - Fax:214-221-7199
Practice Address - Street 1:10605 BOOMER CIR STE 105
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75238-5392
Practice Address - Country:US
Practice Address - Phone:972-365-0084
Practice Address - Fax:214-221-7199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-16
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty