Provider Demographics
NPI:1891245890
Name:EXTENDED QUALITY OF LIFE, LLC
Entity Type:Organization
Organization Name:EXTENDED QUALITY OF LIFE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTONISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAIR
Authorized Official - Suffix:
Authorized Official - Credentials:MSW,LSSW
Authorized Official - Phone:901-315-7652
Mailing Address - Street 1:2677 WIGAN CV
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-0115
Mailing Address - Country:US
Mailing Address - Phone:901-315-7652
Mailing Address - Fax:
Practice Address - Street 1:2677 WIGAN CV
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-0115
Practice Address - Country:US
Practice Address - Phone:901-315-7652
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1000000018653251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health