1578224218 NPI number — ORTHOSOURCE, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578224218 NPI number — ORTHOSOURCE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORTHOSOURCE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578224218
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7510
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGDALE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72766-7510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-872-1885
Provider Business Mailing Address Fax Number:
479-872-1889

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1675 W JEFFERSON ST STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SILOAM SPRINGS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72761-3001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-373-2510
Provider Business Practice Location Address Fax Number:
479-373-2509
Provider Enumeration Date:
01/05/2022

Additional Information

Authorized Official

Authorized Official Last Name:
DEJARNATT
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
HAL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
479-373-2510

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 161293716 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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