Provider Demographics
NPI:1700172392
Name:EXTENDED FAMILY CARE LLC
Entity Type:Organization
Organization Name:EXTENDED FAMILY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR / OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:LONNETTE
Authorized Official - Last Name:DODGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-952-3499
Mailing Address - Street 1:30 POWERS BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355-2806
Mailing Address - Country:US
Mailing Address - Phone:931-954-5225
Mailing Address - Fax:931-954-5221
Practice Address - Street 1:30 POWERS BRIDGE RD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-2806
Practice Address - Country:US
Practice Address - Phone:931-954-5225
Practice Address - Fax:931-954-5221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-22
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNI000000017110251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH445690Medicaid