=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164948196
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXTRA MILE RECOVERY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2017
-----------------------------------------------------
Last Update Date | 01/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 720 OAK GROVE RD
-----------------------------------------------------
City | MANTACHIE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38855
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-246-2946
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 720 OAK GROVE RD
-----------------------------------------------------
City | MANTACHIE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38855
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-246-2946
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | SCOTT SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 901-626-4454
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------