Provider Demographics
NPI:1588294128
Name:ROCKY MOUNTAIN ORTHOPEDIC AND REGENERATIVE MEDICINE LLC
Entity type:Organization
Organization Name:ROCKY MOUNTAIN ORTHOPEDIC AND REGENERATIVE MEDICINE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENDON
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-425-6020
Mailing Address - Street 1:919 S UTAH AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3322
Mailing Address - Country:US
Mailing Address - Phone:208-561-2286
Mailing Address - Fax:
Practice Address - Street 1:919 S UTAH AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3322
Practice Address - Country:US
Practice Address - Phone:208-561-2286
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-23
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty