Healthcare Provider Details

I. General information

NPI: 1013731397
Provider Name (Legal Business Name): BENTONVILLE ENDOSCOPY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2024
Last Update Date: 11/13/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 SE DODSON ROAD SUITE #4
BENTONVILLE AR
72712
US

IV. Provider business mailing address

550 RESERVE ST STE 550
SOUTHLAKE TX
76092-1604
US

V. Phone/Fax

Practice location:
  • Phone: 817-893-2381
  • Fax:
Mailing address:
  • Phone: 214-697-7314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KELLY ROUVALDT
Title or Position: DIRECTOR OF ASCS
Credential:
Phone: 817-893-2381