Provider Demographics
NPI:1104315761
Name:EXTENDED LIFE LLC
Entity type:Organization
Organization Name:EXTENDED LIFE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-351-8288
Mailing Address - Street 1:2850 CEDAR AVE APT 171
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89101-3871
Mailing Address - Country:US
Mailing Address - Phone:702-351-8288
Mailing Address - Fax:
Practice Address - Street 1:2850 CEDAR AVE APT 171
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101-3871
Practice Address - Country:US
Practice Address - Phone:702-351-8288
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-08
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health