Healthcare Provider Details

I. General information

NPI: 1831871250
Provider Name (Legal Business Name): HOLE ORTHO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2023
Last Update Date: 04/29/2024
Certification Date: 04/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 E BROADWAY AVE STE 211
JACKSON WY
83001-8640
US

IV. Provider business mailing address

970 W BROADWAY STE E121
JACKSON WY
83001-6402
US

V. Phone/Fax

Practice location:
  • Phone: 307-699-6801
  • Fax: 307-733-6912
Mailing address:
  • Phone: 307-699-6801
  • Fax: 307-733-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: REBECCA ASHLEY SJOSTROM
Title or Position: OWNER
Credential: MD
Phone: 307-699-6801