Healthcare Provider Details

I. General information

NPI: 1720739972
Provider Name (Legal Business Name): EXTENDED HEALTHCARE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2022
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6740 SHANNON PKWY STE 34
UNION CITY GA
30291-2058
US

IV. Provider business mailing address

823 GARDEN WALK BLVD APT B
COLLEGE PARK GA
30349-6256
US

V. Phone/Fax

Practice location:
  • Phone: 770-681-0374
  • Fax:
Mailing address:
  • Phone: 770-256-9898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. MARY S BATSON
Title or Position: ADMINISTRATOR/OWNER
Credential: RN
Phone: 770-256-9898