Provider Demographics
NPI:1962962761
Name:EXTENDED LIFE PERSONAL CARE STAFFING AGENCY,LLC
Entity type:Organization
Organization Name:EXTENDED LIFE PERSONAL CARE STAFFING AGENCY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-316-7839
Mailing Address - Street 1:310 MID CONTINENT PLZ STE 460
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-1700
Mailing Address - Country:US
Mailing Address - Phone:501-316-7839
Mailing Address - Fax:
Practice Address - Street 1:310 MID CONTINENT PLZ STE 460
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-1700
Practice Address - Country:US
Practice Address - Phone:501-316-7839
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty