Healthcare Provider Details

I. General information

NPI: 1164948196
Provider Name (Legal Business Name): EXTRA MILE RECOVERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 01/07/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 OAK GROVE RD
MANTACHIE MS
38855
US

IV. Provider business mailing address

720 OAK GROVE RD
MANTACHIE MS
38855
US

V. Phone/Fax

Practice location:
  • Phone: 662-246-2946
  • Fax:
Mailing address:
  • Phone: 662-246-2946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: SCOTT SMITH
Title or Position: OWNER/OPERATOR
Credential:
Phone: 901-626-4454