Healthcare Provider Details

I. General information

NPI: 1073376695
Provider Name (Legal Business Name): HIGH DESERT SPORTS AND SPINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2024
Last Update Date: 01/28/2026
Certification Date: 01/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 SW SIMPSON AVE STE 100
BEND OR
97702-3789
US

IV. Provider business mailing address

1140 SW SIMPSON AVE STE 100
BEND OR
97702-3789
US

V. Phone/Fax

Practice location:
  • Phone: 541-388-2333
  • Fax: 541-388-0930
Mailing address:
  • Phone: 541-388-2333
  • Fax: 541-388-0930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: EDWARD JOSEPH KENT
Title or Position: OWNER
Credential: MD
Phone: 208-500-8667