Provider Demographics
NPI:1326228370
Name:ADVANCED AMBULATORY SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:ADVANCED AMBULATORY SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:BRANDON
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-568-8494
Mailing Address - Street 1:1444 E STEARNS ST
Mailing Address - Street 2:SUITE 15
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-6243
Mailing Address - Country:US
Mailing Address - Phone:479-966-4972
Mailing Address - Fax:479-966-4655
Practice Address - Street 1:1444 E STEARNS ST
Practice Address - Street 2:SUITE 15
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-6243
Practice Address - Country:US
Practice Address - Phone:479-966-4972
Practice Address - Fax:479-966-4655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
478741OtherJACHO
ARAR4579OtherSTATE OF ARKANSAS DEPARTMENT OF HEALTH
ARAR4579OtherSTATE OF ARKANSAS DEPARTMENT OF HEALTH