Provider Demographics
NPI:1831871250
Name:HOLE ORTHO LLC
Entity type:Organization
Organization Name:HOLE ORTHO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:ASHLEY
Authorized Official - Last Name:SJOSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-699-6801
Mailing Address - Street 1:970 W BROADWAY STE E121
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-6402
Mailing Address - Country:US
Mailing Address - Phone:307-699-6801
Mailing Address - Fax:307-733-6912
Practice Address - Street 1:555 E BROADWAY AVE STE 211
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8640
Practice Address - Country:US
Practice Address - Phone:307-699-6801
Practice Address - Fax:307-733-6912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-04
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty