Provider Demographics
NPI:1962515783
Name:ADVANCED TISSUE, LLC
Entity type:Organization
Organization Name:ADVANCED TISSUE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:LAMB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-217-9900
Mailing Address - Street 1:7003 VALLEY RANCH DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-4696
Mailing Address - Country:US
Mailing Address - Phone:501-217-9900
Mailing Address - Fax:501-217-9939
Practice Address - Street 1:7003 VALLEY RANCH DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72223-4696
Practice Address - Country:US
Practice Address - Phone:501-217-9900
Practice Address - Fax:501-217-9939
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AT BUYER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-16
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009966110Medicaid
DE1000037816Medicaid
MS0440992Medicaid
AZ733982Medicaid
ID806569500Medicaid
AKMS151ARMedicaid
AR143955716Medicaid
MD401946600Medicaid
IN200446340AMedicaid
MN984669700Medicaid
ME431825000Medicaid
KY90003740Medicaid
CO34637036Medicaid
CT0031177Medicaid
IA0563775Medicaid
LA1153184Medicaid
MI874487746Medicaid
GA000979536AMedicaid
MS0440992Medicaid
KY90003740Medicaid