Healthcare Provider Details

I. General information

NPI: 1932853561
Provider Name (Legal Business Name): ORTHOPEDIC SPORTS TRAUMA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2022
Last Update Date: 02/11/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 E BROADWAY AVE
JACKSON WY
83001-8636
US

IV. Provider business mailing address

PO BOX 1806
JACKSON WY
83001-1806
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-2443
  • Fax: 307-733-6912
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: RHETT J GRIGGS
Title or Position: SOLE OWNER
Credential: MD
Phone: 970-901-1287