Healthcare Provider Details

I. General information

NPI: 1134741945
Provider Name (Legal Business Name): EXTENDED CARE CLINICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2020
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 BROOKWAY BLVD
BROOKHAVEN MS
39601-3266
US

IV. Provider business mailing address

PO BOX 197
BROOKHAVEN MS
39602-0197
US

V. Phone/Fax

Practice location:
  • Phone: 601-833-5255
  • Fax: 601-843-0252
Mailing address:
  • Phone: 601-833-5255
  • Fax: 601-843-0252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. MALLORY MOWDY
Title or Position: PRESIDENT
Credential: N.P.
Phone: 601-730-0602