MEDICARE: EXTENDED FAMILY CARE 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	172V00000X	Community Health Worker		LA

General Provider Information

NPI Number	:	1164770566
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXTENDED FAMILY CARE LLC

Provider Business Mailing Address
First Line	:	PO BOX 353
Second Line	:	3309 ASHLEY DR
City	:	VIOLET
State	:	LA
Zip	:	70092-0353
Country	:	US
Telephone Number	:	504-231-1060
Fax Number	:

Provider Business Practice Location Address
First Line	:	3309 ASHLEY DR
Second Line	:	3309 ASHLEY
City	:	VIOLET
State	:	LA
Zip	:	70092-2837
Country	:	US
Telephone Number	:	504-231-1060
Fax Number	:

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	MS. ADA MAIRE JOHNSON
Credential	:
Telephone Number	:	504-231-1060

Provider Enumeration Date	:	08/16/2012
Last Update Date	:	08/16/2012

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Directions to “EXTENDED FAMILY CARE LLC ” Practice Location

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