Provider Demographics
NPI:1982224556
Name:GREAT RIVER ORTHOPEDIC AND SPORTS MEDICINE CENTER, INC.
Entity Type:Organization
Organization Name:GREAT RIVER ORTHOPEDIC AND SPORTS MEDICINE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:F
Authorized Official - Last Name:TRAINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-404-4075
Mailing Address - Street 1:800 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446-4750
Mailing Address - Country:US
Mailing Address - Phone:423-337-4075
Mailing Address - Fax:
Practice Address - Street 1:376 COCOVILLE RD
Practice Address - Street 2:
Practice Address - City:MANSURA
Practice Address - State:LA
Practice Address - Zip Code:71350-4264
Practice Address - Country:US
Practice Address - Phone:337-404-4075
Practice Address - Fax:337-404-4069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-23
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty