Provider Demographics
NPI:1780218289
Name:ORTHO EXPRESS HOLDING COMPANY, LLC
Entity Type:Organization
Organization Name:ORTHO EXPRESS HOLDING COMPANY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:C
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-534-2298
Mailing Address - Street 1:206 OXFORD RD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-3115
Mailing Address - Country:US
Mailing Address - Phone:662-534-2227
Mailing Address - Fax:662-536-7520
Practice Address - Street 1:3952 N GLOSTER ST STE C
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-0913
Practice Address - Country:US
Practice Address - Phone:662-350-0737
Practice Address - Fax:662-534-2330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-24
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Multi-Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty