Provider Demographics
NPI:1386177376
Name:EXECUTIVE SURGERY CENTER OF LITTLE ROCK, LLC
Entity type:Organization
Organization Name:EXECUTIVE SURGERY CENTER OF LITTLE ROCK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRITNEY
Authorized Official - Middle Name:DESHAE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:501-312-2121
Mailing Address - Street 1:11220 EXECUTIVE CENTER DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4320
Mailing Address - Country:US
Mailing Address - Phone:501-312-2121
Mailing Address - Fax:501-312-2330
Practice Address - Street 1:11220 EXECUTIVE CENTER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-4320
Practice Address - Country:US
Practice Address - Phone:501-312-2121
Practice Address - Fax:501-312-2330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-06
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
6098850OtherAETNA
3130254OtherFIRST HEALTH
AR225821128Medicaid
970544OtherAETNA COVENTRY