Provider Demographics
NPI:1497293054
Name:CENTRAL OREGON SPINE AND SPORTS, LLC
Entity Type:Organization
Organization Name:CENTRAL OREGON SPINE AND SPORTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOOHER
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:541-420-4833
Mailing Address - Street 1:2115 NE WYATT CT
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7678
Mailing Address - Country:US
Mailing Address - Phone:541-420-4833
Mailing Address - Fax:541-228-3670
Practice Address - Street 1:2115 NE WYATT CT
Practice Address - Street 2:SUITE 101
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7678
Practice Address - Country:US
Practice Address - Phone:541-420-4833
Practice Address - Fax:541-228-3670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD152056208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR=========OtherTAX ID