1922070911 NPI number — FAYETTEVILLE ASC LLC

Table of content: (NPI 1922070911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922070911 NPI number — FAYETTEVILLE ASC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAYETTEVILLE ASC 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:
Provider Other Organization Name Type Code:
6
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:
1922070911
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1A BURTON HILLS BLVD STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37215-6153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-263-4011
Provider Business Mailing Address Fax Number:
615-234-1720

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3344 N FUTRALL DR
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72703-4057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-582-7280
Provider Business Practice Location Address Fax Number:
615-234-1720
Provider Enumeration Date:
02/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SNODGRASS
Authorized Official First Name:
JEFF
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
615-665-1283

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  AR3230 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 131577128 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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