Provider Demographics
NPI:1477554921
Name:HIGH DESERT HEALTHCARE
Entity Type:Organization
Organization Name:HIGH DESERT HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:KNOWER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-447-1680
Mailing Address - Street 1:1251 NE ELM STREET
Mailing Address - Street 2:
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754
Mailing Address - Country:US
Mailing Address - Phone:541-447-1680
Mailing Address - Fax:541-447-4670
Practice Address - Street 1:1251 NE ELM STREET
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754
Practice Address - Country:US
Practice Address - Phone:541-447-1680
Practice Address - Fax:541-447-4670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15601261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
H3079OtherPACIFIC SOURCE
GRP331OtherPROVIDENCE HEALTH PLANS
CH6131OtherRAILROAD MEDICARE
OR213187Medicaid
=========OtherTRICARE WEST
H3079OtherPACIFIC SOURCE
ORR106863Medicare ID - Type UnspecifiedMEDICARE PART B
C91360Medicare UPIN
OR383860Medicare ID - Type UnspecifiedRIVERBEND - RHC