Provider Demographics
NPI:1134741945
Name:EXTENDED CARE CLINICAL SERVICES LLC
Entity type:Organization
Organization Name:EXTENDED CARE CLINICAL SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MALLORY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOWDY
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:601-730-0602
Mailing Address - Street 1:PO BOX 197
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39602-0197
Mailing Address - Country:US
Mailing Address - Phone:601-833-5255
Mailing Address - Fax:601-843-0252
Practice Address - Street 1:525 BROOKWAY BLVD
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-3266
Practice Address - Country:US
Practice Address - Phone:601-833-5255
Practice Address - Fax:601-843-0252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-14
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health