Provider Demographics
NPI:1841797651
Name:EXTENSIONS OF LIFE LLC
Entity Type:Organization
Organization Name:EXTENSIONS OF LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DONDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:504-322-7710
Mailing Address - Street 1:PO BOX 2578
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70054-2578
Mailing Address - Country:US
Mailing Address - Phone:504-322-7710
Mailing Address - Fax:504-322-7708
Practice Address - Street 1:1400 CALDER ST
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70053-5637
Practice Address - Country:US
Practice Address - Phone:504-322-7710
Practice Address - Fax:504-322-7708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-09
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health