Provider Demographics
NPI:1982829453
Name:EXTENSIONS OF LIVING, L.L.C.
Entity Type:Organization
Organization Name:EXTENSIONS OF LIVING, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING OFFICER STAFF NURSE
Authorized Official - Prefix:
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:ALEXANDRIA
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:252-514-2727
Mailing Address - Street 1:4939 BRAGG BLVD
Mailing Address - Street 2:SUITE #202
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-3686
Mailing Address - Country:US
Mailing Address - Phone:910-485-8370
Mailing Address - Fax:252-514-2770
Practice Address - Street 1:4939 BRAGG BLVD
Practice Address - Street 2:SUITE #202
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-3686
Practice Address - Country:US
Practice Address - Phone:910-485-8370
Practice Address - Fax:252-514-2770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC3021251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCHC3021Medicaid