MEDICARE: EXTENDED LIFE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1104315761
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXTENDED LIFE LLC

Provider Business Mailing Address
First Line	:	2850 CEDAR AVE APT 171
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89101-3871
Country	:	US
Telephone Number	:	702-351-8288
Fax Number	:

Provider Business Practice Location Address
First Line	:	2850 CEDAR AVE APT 171
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89101-3871
Country	:	US
Telephone Number	:	702-351-8288
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	ASHLEE BROWN
Credential	:
Telephone Number	:	702-351-8288

Provider Enumeration Date	:	05/08/2018
Last Update Date	:	06/16/2018

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Directions to “EXTENDED LIFE LLC ” Practice Location

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