Healthcare Provider Details

I. General information

NPI: 1821904863
Provider Name (Legal Business Name): 643 EXTENDERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 LINE AVE STE 204
SHREVEPORT LA
71101-4648
US

IV. Provider business mailing address

717 CROCKETT ST
SHREVEPORT LA
71101-3605
US

V. Phone/Fax

Practice location:
  • Phone: 318-629-5496
  • Fax:
Mailing address:
  • Phone: 318-629-5496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN DAVID GOOGE
Title or Position: PRESIDENT
Credential: MD
Phone: 318-629-5496