Provider Demographics
NPI:1982873626
Name:ADVOCATE MEDICAL SUPPORT GROUP
Entity type:Organization
Organization Name:ADVOCATE MEDICAL SUPPORT GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:K
Authorized Official - Last Name:VANDEEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-394-1600
Mailing Address - Street 1:300 CRESTWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-5515
Mailing Address - Country:US
Mailing Address - Phone:479-394-1600
Mailing Address - Fax:479-394-1606
Practice Address - Street 1:300 CRESTWOOD CIR
Practice Address - Street 2:
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-5515
Practice Address - Country:US
Practice Address - Phone:479-394-1600
Practice Address - Fax:479-394-1606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 332B00000X
AR133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty