Basic Information
| Provider Information | |||||||||
| NPI: | 1356474993 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ASCENT ACQUISITIONS CORP-CYPDC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CHILD & YOUTH PEDIATRIC DAY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3012 TURMAN DR | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724048998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708190200 | ||||||||
| FaxNumber: | 8708190217 | ||||||||
| Practice Location | |||||||||
| Address1: | 2040 FITZHUGH ST | ||||||||
| Address2: | |||||||||
| City: | BATESVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725017409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707933334 | ||||||||
| FaxNumber: | 8707933474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 03/01/2012 | ||||||||
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| AuthorizedOfficialLastName: | ALLGOOD | ||||||||
| AuthorizedOfficialFirstName: | HOLLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 8708190232 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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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 | 5C363 | 01 | AR | BCBS | OTHER | 160759724 | 05 | AR | MEDICAID | 160744742 | 05 | AR | MEDICAID | 160745526 | 05 | AR | MEDICAID |