Basic Information
| Provider Information | |||||||||
| NPI: | 1427662345 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BENTONVILLE AMBULATORY SURGERY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 108 N SHACKLEFORD RD | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722112840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5077736993 | ||||||||
| FaxNumber: | 8886308885 | ||||||||
| Practice Location | |||||||||
| Address1: | 2902 MID CITIES DR | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727124020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8442150731 | ||||||||
| FaxNumber: | 8886308885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2020 | ||||||||
| LastUpdateDate: | 02/16/2022 | ||||||||
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| AuthorizedOfficialLastName: | WADDELL | ||||||||
| AuthorizedOfficialFirstName: | EILIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | ASC ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5017661065 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | 02/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.