Provider Demographics
NPI:1871090514
Name:EXTRACARE LLC
Entity type:Organization
Organization Name:EXTRACARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KASAYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-806-4465
Mailing Address - Street 1:5969 E LIVINGSTON AVE STE 209
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-2907
Mailing Address - Country:US
Mailing Address - Phone:614-806-4465
Mailing Address - Fax:
Practice Address - Street 1:5969 E LIVINGSTON AVE STE 209
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-2907
Practice Address - Country:US
Practice Address - Phone:614-806-4465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-10
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0108317Medicaid