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General NPI Number Information
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NPI Number | 1134741945
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Entity Type | Organization
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Legal Business Name | EXTENDED CARE CLINICAL SERVICES LLC
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Dates
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Enumeration Date | 05/14/2020
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Last Update Date | 10/29/2025
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Provider Practice Location Address
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Address Line | 545 BROOKWAY BLVD
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City | BROOKHAVEN
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State | MS
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Zip | 39601-3266
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Country | US
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Telephone | 601-833-5255
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Fax | 601-843-0252
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Provider Business Mailing Address
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Address Line | PO BOX 197
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City | BROOKHAVEN
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State | MS
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Zip | 39602-0197
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Country | US
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Telephone | 601-833-5255
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Fax | 601-843-0252
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Authorized Official
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Title or Position | PRESIDENT
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Name | MRS. MALLORY MOWDY
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Credential | N.P.
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Telephone | 601-730-0602
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State | NULL
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Taxonomy #2
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State | NULL
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