# 643 EXTENDERS LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1821904863
- **Authorized official:** DR. JOHN DAVID GOOGE MD (PRESIDENT)
- **Authorized official phone:** (318) 629-5496

## Contact information

- **Practice address:** 1500 LINE AVE STE 204, SHREVEPORT, LA 71101-4648
- **Practice address phone:** (318) 629-5496
- **Mailing address:** 717 CROCKETT ST, SHREVEPORT, LA 71101-3605
- **Mailing address phone:** (318) 629-5496

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 363AS0400X | Surgical Physician Assistant | — | NULL | Yes |
| 363AS0400X | Surgical Physician Assistant | — | — | Yes |

## Other

- **Enumeration date:** 08/20/2026
- **Last updated:** 08/20/2026