Provider Demographics
NPI:1073376695
Name:HIGH DESERT SPORTS AND SPINE, LLC
Entity Type:Organization
Organization Name:HIGH DESERT SPORTS AND SPINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:KENT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-500-8667
Mailing Address - Street 1:1140 SW SIMPSON AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3789
Mailing Address - Country:US
Mailing Address - Phone:541-388-2333
Mailing Address - Fax:541-388-0930
Practice Address - Street 1:1140 SW SIMPSON AVE STE 100
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3789
Practice Address - Country:US
Practice Address - Phone:541-388-2333
Practice Address - Fax:541-388-0930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-05
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty