Provider Demographics
NPI:1164770566
Name:EXTENDED FAMILY CARE LLC
Entity Type:Organization
Organization Name:EXTENDED FAMILY CARE LLC
Other - Org Name:EXTENDED FAMILY CARE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ADA
Authorized Official - Middle Name:MAIRE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-231-1060
Mailing Address - Street 1:PO BOX 353
Mailing Address - Street 2:3309 ASHLEY DR
Mailing Address - City:VIOLET
Mailing Address - State:LA
Mailing Address - Zip Code:70092-0353
Mailing Address - Country:US
Mailing Address - Phone:504-231-1060
Mailing Address - Fax:
Practice Address - Street 1:3309 ASHLEY DR
Practice Address - Street 2:3309 ASHLEY
Practice Address - City:VIOLET
Practice Address - State:LA
Practice Address - Zip Code:70092-2837
Practice Address - Country:US
Practice Address - Phone:504-231-1060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty