Basic Information
| Provider Information | |||||||||
| NPI: | 1588802987 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NATIONAL PARK ENDOSCOPY CENTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTH CENTRAL ENDOSCOPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 SAWTOOTH OAK ST | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719017160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016237800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 124 SAWTOOTH OAK ST. | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 71901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016237800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2009 | ||||||||
| LastUpdateDate: | 03/29/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DILLON | ||||||||
| AuthorizedOfficialFirstName: | TERRANCE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5025967220 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | AR5205 | AR | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 219000128 | 05 | AR | MEDICAID |