Provider Demographics
NPI:1376662981
Name:EXTENDED ENTERPRISES, INC
Entity Type:Organization
Organization Name:EXTENDED ENTERPRISES, INC
Other - Org Name:EHS MEDICAL EQUIPMENT & SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:D
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-359-2930
Mailing Address - Street 1:PO BOX 393
Mailing Address - Street 2:
Mailing Address - City:HAYTI
Mailing Address - State:MO
Mailing Address - Zip Code:63851-0393
Mailing Address - Country:US
Mailing Address - Phone:573-359-2930
Mailing Address - Fax:573-359-1304
Practice Address - Street 1:110 N HIGHWAY J
Practice Address - Street 2:
Practice Address - City:HAYTI
Practice Address - State:MO
Practice Address - Zip Code:63851
Practice Address - Country:US
Practice Address - Phone:573-359-0403
Practice Address - Fax:573-359-2136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO320900000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO858892508Medicaid