Provider Demographics
NPI:1073885679
Name:DES MOINES SPINE & SPORT PLLC
Entity Type:Organization
Organization Name:DES MOINES SPINE & SPORT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:ROED
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:515-493-9188
Mailing Address - Street 1:1770 92ND ST
Mailing Address - Street 2:UNIT 10301
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-1596
Mailing Address - Country:US
Mailing Address - Phone:515-493-9188
Mailing Address - Fax:
Practice Address - Street 1:1770 92ND ST
Practice Address - Street 2:UNIT 10301
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1596
Practice Address - Country:US
Practice Address - Phone:515-493-9188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA007498111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty