1962515783 NPI number — ADVANCED TISSUE, LLC

Table of content: (NPI 1962515783)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962515783 NPI number — ADVANCED TISSUE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED TISSUE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ADVANCED TISSUE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962515783
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7003 VALLEY RANCH DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72223-4696
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-217-9900
Provider Business Mailing Address Fax Number:
501-217-9939

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7003 VALLEY RANCH DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72223-4696
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-217-9900
Provider Business Practice Location Address Fax Number:
501-217-9939
Provider Enumeration Date:
08/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LAMB
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
KEVIN
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
501-217-9900

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 009966110 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1000037816 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0440992 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 733982 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 806569500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: MS151AR , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 143955716 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 401946600 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200446340A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 984669700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 431825000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 90003740 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 34637036 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0031177 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0563775 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1153184 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 874487746 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000979536A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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