Provider Demographics
NPI:1124648860
Name:ORTHOSPINE DME, LLC
Entity type:Organization
Organization Name:ORTHOSPINE DME, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-402-3807
Mailing Address - Street 1:5315 OLD HIGHWAY 11
Mailing Address - Street 2:STE 4
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-6224
Mailing Address - Country:US
Mailing Address - Phone:800-484-1851
Mailing Address - Fax:800-484-1851
Practice Address - Street 1:5315 OLD HIGHWAY 11 STE 4
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-6224
Practice Address - Country:US
Practice Address - Phone:800-484-1851
Practice Address - Fax:800-484-1851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-23
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS18041-11.1OtherMISSISSIPPI BOARD OF PHARMACY - MEDICAL EQUIPMENT SUPPLIER LICENSE