Provider Demographics
NPI:1154016475
Name:THE EXTRA MILE, REGION IV, INC.
Entity type:Organization
Organization Name:THE EXTRA MILE, REGION IV, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALS
Authorized Official - Prefix:
Authorized Official - First Name:HALLIE
Authorized Official - Middle Name:W
Authorized Official - Last Name:ALLGOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-237-2090
Mailing Address - Street 1:720 SAINT JOHN ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501-6706
Mailing Address - Country:US
Mailing Address - Phone:337-237-2090
Mailing Address - Fax:337-237-2083
Practice Address - Street 1:808 PITT RD
Practice Address - Street 2:
Practice Address - City:SCOTT
Practice Address - State:LA
Practice Address - Zip Code:70583-4608
Practice Address - Country:US
Practice Address - Phone:337-337-8064
Practice Address - Fax:337-237-2083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder