Provider Demographics
NPI:1326822404
Name:ORTIS, CLINT JOSEPH
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:JOSEPH
Last Name:ORTIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6642 FALSE RIVER RD
Mailing Address - Street 2:
Mailing Address - City:OSCAR
Mailing Address - State:LA
Mailing Address - Zip Code:70762
Mailing Address - Country:US
Mailing Address - Phone:225-718-0307
Mailing Address - Fax:
Practice Address - Street 1:6515 SULLIVAN RD
Practice Address - Street 2:
Practice Address - City:GREENWELL SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70739-3110
Practice Address - Country:US
Practice Address - Phone:225-718-0307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA024921183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist