Basic Information
Provider Information | |||||||||
NPI: | 1124151220 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ASCENT ACQUISITIONS CORP-PSC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PEDIATRIC SPECIALTY CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3012 TURMAN DR | ||||||||
Address2: |   | ||||||||
City: | JONESBORO | ||||||||
State: | AR | ||||||||
PostalCode: | 724048998 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8708190200 | ||||||||
FaxNumber: | 8708190217 | ||||||||
Practice Location | |||||||||
Address1: | 1510 BYRUM RD | ||||||||
Address2: |   | ||||||||
City: | BLYTHEVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 723158033 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8705322600 | ||||||||
FaxNumber: | 8705329484 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/14/2007 | ||||||||
LastUpdateDate: | 04/12/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ALLGOOD | ||||||||
AuthorizedOfficialFirstName: | HOLLY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 8708190232 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 235Z00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 251C00000X |   |   | Y |   | Agencies | Day Training, Developmentally Disabled Services |   |
ID Information
ID | Type | State | Issuer | Description | 160779526 | 05 | AR |   | MEDICAID | 161010724 | 05 | AR |   | MEDICAID | 160787742 | 05 | AR |   | MEDICAID | 5C082 | 01 | AR | BCBS | OTHER |