Provider Demographics
NPI:1689890063
Name:ASCENSION DEPAUL SERVICES
Entity Type:Organization
Organization Name:ASCENSION DEPAUL SERVICES
Other - Org Name:ASCENSION DEPAUL SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODGAME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-382-3080
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:DUMAS
Mailing Address - State:AR
Mailing Address - Zip Code:71639-0158
Mailing Address - Country:US
Mailing Address - Phone:870-382-3080
Mailing Address - Fax:870-382-3085
Practice Address - Street 1:407 SOUTH GOULD AVE
Practice Address - Street 2:
Practice Address - City:GOULD
Practice Address - State:AR
Practice Address - Zip Code:71643
Practice Address - Country:US
Practice Address - Phone:870-263-4317
Practice Address - Fax:870-263-4782
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASCENSION DEPAUL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-17
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR149324631Medicaid