Healthcare Provider Details

I. General information

NPI: 1962029249
Provider Name (Legal Business Name): ORTHO EXPRESS HOLDING COMPANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2020
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 W CHURCH ST
BOONEVILLE MS
38829
US

IV. Provider business mailing address

206 OXFORD RD
NEW ALBANY MS
38652-3115
US

V. Phone/Fax

Practice location:
  • Phone: 662-534-2227
  • Fax: 662-534-2330
Mailing address:
  • Phone: 662-534-2227
  • Fax: 662-534-2330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER C BULLOCK
Title or Position: PRESIDENT
Credential:
Phone: 662-534-2227