Provider Demographics
NPI:1164948196
Name:EXTRA MILE RECOVERY
Entity Type:Organization
Organization Name:EXTRA MILE RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE/CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:FARRAR
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, NCC, CADC-II
Authorized Official - Phone:662-321-2329
Mailing Address - Street 1:720 OAK GROVE RD
Mailing Address - Street 2:
Mailing Address - City:MANTACHIE
Mailing Address - State:MS
Mailing Address - Zip Code:38855-8469
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:720 OAK GROVE RD
Practice Address - Street 2:
Practice Address - City:MANTACHIE
Practice Address - State:MS
Practice Address - Zip Code:38855-8469
Practice Address - Country:US
Practice Address - Phone:662-321-2329
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-22
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility