Basic Information
| Provider Information | |||||||||
| NPI: | 1134741945 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EXTENDED CARE CLINICAL SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40018 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708350018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259064646 | ||||||||
| FaxNumber: | 2257530948 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 MILLS ST | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396012521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259064646 | ||||||||
| FaxNumber: | 2257530948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2020 | ||||||||
| LastUpdateDate: | 05/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | DASPIT | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2259064646 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | SR. | ||||||||
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| NPICertificationDate: | 05/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.