Healthcare Provider Details

I. General information

NPI: 1588294128
Provider Name (Legal Business Name): ROCKY MOUNTAIN ORTHOPEDIC AND REGENERATIVE MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2020
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 S UTAH AVE
IDAHO FALLS ID
83402-3322
US

IV. Provider business mailing address

919 S UTAH AVE
IDAHO FALLS ID
83402-3322
US

V. Phone/Fax

Practice location:
  • Phone: 208-561-2286
  • Fax:
Mailing address:
  • Phone: 208-561-2286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: KENDON HOWARD
Title or Position: CEO
Credential:
Phone: 208-425-6020