Provider Demographics
NPI:1225659956
Name:EXTENDED FAMILY CARE LLC
Entity Type:Organization
Organization Name:EXTENDED FAMILY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:L
Authorized Official - Last Name:DODGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-952-3499
Mailing Address - Street 1:PO BOX 870
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37349-0870
Mailing Address - Country:US
Mailing Address - Phone:931-295-6252
Mailing Address - Fax:931-954-0856
Practice Address - Street 1:1001 MCARTHUR ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-2419
Practice Address - Country:US
Practice Address - Phone:931-295-0856
Practice Address - Fax:931-954-0856
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EXTENDED FAMILY CARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-05-05
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH445690Medicaid