Basic Information
| Provider Information | |||||||||
| NPI: | 1902937519 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HIGH DESERT MEDICAL SUPPLY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1251 NE ELM ST STE 1B | ||||||||
| Address2: | |||||||||
| City: | PRINEVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977543143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414474688 | ||||||||
| FaxNumber: | 5414471243 | ||||||||
| Practice Location | |||||||||
| Address1: | 1251 NE ELM ST STE 1B | ||||||||
| Address2: | |||||||||
| City: | PRINEVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977543143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414474688 | ||||||||
| FaxNumber: | 5414471243 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5414474688 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | NPC-0002734 | OR | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 275466 | 05 | OR | MEDICAID |