Provider Demographics
NPI:1811514870
Name:ASCEND LLC
Entity type:Organization
Organization Name:ASCEND LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:F
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-419-3002
Mailing Address - Street 1:2001 S WOODRUFF AVE STE 9
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6371
Mailing Address - Country:US
Mailing Address - Phone:208-419-3002
Mailing Address - Fax:208-656-5652
Practice Address - Street 1:2001 S WOODRUFF AVE STE 9
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6371
Practice Address - Country:US
Practice Address - Phone:208-419-3002
Practice Address - Fax:208-656-5652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-25
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20007264Medicaid