Healthcare Provider Details

I. General information

NPI: 1780218289
Provider Name (Legal Business Name): ORTHO EXPRESS HOLDING COMPANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2020
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3952 N GLOSTER ST STE C
TUPELO MS
38804-0913
US

IV. Provider business mailing address

206 OXFORD RD
NEW ALBANY MS
38652-3115
US

V. Phone/Fax

Practice location:
  • Phone: 662-350-0737
  • Fax: 662-534-2330
Mailing address:
  • Phone: 662-534-2227
  • Fax: 662-536-7520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER C BULLOCK
Title or Position: PRESIDENT
Credential:
Phone: 662-534-2298