1417005455 NPI number — GORGE BONE DENSITY TESTING

Table of content: (NPI 1417005455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417005455 NPI number — GORGE BONE DENSITY TESTING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GORGE BONE DENSITY TESTING
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FRAN M YUHAS
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417005455
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1825 E 19TH ST
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
THE DALLES
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97058-3365
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-493-1467
Provider Business Mailing Address Fax Number:
509-493-3765

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1825 E 19TH ST
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
THE DALLES
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97058-3365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-493-1467
Provider Business Practice Location Address Fax Number:
509-493-3765
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NICHOL
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OPERATING MANAGER
Authorized Official Telephone Number:
509-493-1467

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  MD17839 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: K285402 . This is a "PACIFIC SOURCE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 064659 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1088970 . This is a "WASHINGTON MEDICAID" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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