Provider Demographics
NPI:1013731397
Name:BENTONVILLE ENDOSCOPY CENTER, LLC
Entity type:Organization
Organization Name:BENTONVILLE ENDOSCOPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ASCS
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUVALDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-893-2381
Mailing Address - Street 1:550 RESERVE ST STE 550
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-1604
Mailing Address - Country:US
Mailing Address - Phone:214-697-7314
Mailing Address - Fax:
Practice Address - Street 1:3700 SE DODSON ROAD
Practice Address - Street 2:SUITE #4
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712
Practice Address - Country:US
Practice Address - Phone:817-893-2381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE GI ALLIANCE ACQUISITION, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical