Provider Demographics
NPI:1477823169
Name:EXTENSIONS OF LIVING, LLC
Entity Type:Organization
Organization Name:EXTENSIONS OF LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-582-4695
Mailing Address - Street 1:301 HUMBLE AVE
Mailing Address - Street 2:SUITE 174
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-6365
Mailing Address - Country:US
Mailing Address - Phone:601-582-4695
Mailing Address - Fax:601-582-8178
Practice Address - Street 1:301 HUMBLE AVE
Practice Address - Street 2:SUITE 174
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-6365
Practice Address - Country:US
Practice Address - Phone:601-582-4695
Practice Address - Fax:601-582-8178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07589517376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07628574Medicaid
MS07589517Medicaid