Healthcare Provider Details

I. General information

NPI: 1841797651
Provider Name (Legal Business Name): EXTENSIONS OF LIFE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 08/07/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 CALDER ST
GRETNA LA
70053-5637
US

IV. Provider business mailing address

PO BOX 2578
GRETNA LA
70054-2578
US

V. Phone/Fax

Practice location:
  • Phone: 504-322-7710
  • Fax: 504-322-7708
Mailing address:
  • Phone: 504-322-7710
  • Fax: 504-322-7708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DONDRA FISHER
Title or Position: DIRECTOR
Credential: LMSW
Phone: 504-322-7710