Provider Demographics
NPI:1922051184
Name:ORTHOPAEDICS OF JACKSON HOLE
Entity Type:Organization
Organization Name:ORTHOPAEDICS OF JACKSON HOLE
Other - Org Name:TETON ORTHOPAEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE OPERATIONS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-365-6560
Mailing Address - Street 1:555 E BROADWAY
Mailing Address - Street 2:P.O. BOX 10490
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-9496
Mailing Address - Country:US
Mailing Address - Phone:307-733-3900
Mailing Address - Fax:
Practice Address - Street 1:555 E BROADWAY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-9496
Practice Address - Country:US
Practice Address - Phone:307-733-3900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYN/A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty