Basic Information
| Provider Information | |||||||||
| NPI: | 1497293054 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL OREGON SPINE AND SPORTS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2115 NE WYATT CT | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977017678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414204833 | ||||||||
| FaxNumber: | 5412283670 | ||||||||
| Practice Location | |||||||||
| Address1: | 2115 NE WYATT CT | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977017678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414204833 | ||||||||
| FaxNumber: | 5412283670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2017 | ||||||||
| LastUpdateDate: | 02/03/2017 | ||||||||
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| AuthorizedOfficialLastName: | BOOHER | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5414204833 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | BA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | MD152056 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.