Provider Demographics
NPI:1922353697
Name:EXTENDED LIFE HOME CARE
Entity Type:Organization
Organization Name:EXTENDED LIFE HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:J
Authorized Official - Last Name:ERHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-426-2087
Mailing Address - Street 1:4024 AVONDALE DR
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0635
Mailing Address - Country:US
Mailing Address - Phone:701-426-2087
Mailing Address - Fax:
Practice Address - Street 1:4024 AVONDALE DR
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0635
Practice Address - Country:US
Practice Address - Phone:701-426-2087
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-19
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care