Basic Information
| Provider Information | |||||||||
| NPI: | 1326399072 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ASCENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 806 GLENDALE | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709339528 | ||||||||
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| Practice Location | |||||||||
| Address1: | 806 GLENDALE ST | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724014455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709339528 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2012 | ||||||||
| LastUpdateDate: | 09/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | HAMILTON | ||||||||
| AuthorizedOfficialFirstName: | SHAN | ||||||||
| AuthorizedOfficialMiddleName: | REANN | ||||||||
| AuthorizedOfficialTitleorPosition: | LEAD EDCT | ||||||||
| AuthorizedOfficialTelephone: | 8709339528 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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| AuthorizedOfficialCredential: | LEAD EDCT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 104100000 | 05 | AR | MEDICAID |