Provider Demographics
NPI:1962777268
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:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:C
Authorized Official - Last Name:BOUDREAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-237-2090
Mailing Address - Street 1:525 S BUCHANAN ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501-6815
Mailing Address - Country:US
Mailing Address - Phone:337-237-2090
Mailing Address - Fax:337-237-2083
Practice Address - Street 1:525 S BUCHANAN ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-6815
Practice Address - Country:US
Practice Address - Phone:337-237-2090
Practice Address - Fax:337-237-2083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health