Provider Demographics
NPI:1386784304
Name:ASCENSION PROVIDENCE
Entity type:Organization
Organization Name:ASCENSION PROVIDENCE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REG DIR NET REV & REIMB
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-324-3269
Mailing Address - Street 1:PO BOX 206121
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-6121
Mailing Address - Country:US
Mailing Address - Phone:254-751-4915
Mailing Address - Fax:254-751-4916
Practice Address - Street 1:405 LONDONDERRY DR STE 104
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7920
Practice Address - Country:US
Practice Address - Phone:254-751-4915
Practice Address - Fax:254-751-4916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX144913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX370017Medicaid
2099862OtherPK