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General NPI Number Information
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NPI Number | 1376279463
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Entity Type | Organization
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Legal Business Name | MTN ORTHOXPRESS HOLDINGS, LLC
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Dates
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Enumeration Date | 07/29/2022
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Last Update Date | 06/10/2024
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Provider Practice Location Address
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Address Line | 11645 HIGHWAY 51 S STE 103
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City | ATOKA
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State | TN
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Zip | 38004-2001
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Country | US
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Telephone | 901-407-2221
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Fax | 901-407-2300
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Provider Business Mailing Address
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Address Line | 206 OXFORD RD
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City | NEW ALBANY
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State | MS
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Zip | 38652-3115
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Country | US
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Telephone | 662-534-2227
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Fax | 662-534-5542
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Authorized Official
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Title or Position | PRESIDENT
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Name | JENNIFER C BULLOCK
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Credential |
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Telephone | 662-534-2227
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207XX0005X
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Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
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License Number |
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License Number State |
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