Healthcare Provider Details

I. General information

NPI: 1982388393
Provider Name (Legal Business Name): EXTENDACARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2509 NORTH NASH STREET B
WILSON NC
27896
US

IV. Provider business mailing address

2509 NASH STREET NORTH STE B
WILSON NC
27896-9015
US

V. Phone/Fax

Practice location:
  • Phone: 252-298-5165
  • Fax: 252-616-3718
Mailing address:
  • Phone: 252-298-5165
  • Fax: 252-616-3718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: QUANISHA M KING
Title or Position: DIRECTOR OF OPERATIONS
Credential: RN BSN
Phone: 252-298-5165