Provider Demographics
NPI:1083652085
Name:MERIDIAN BONE DENSITY SPECIALIST
Entity Type:Organization
Organization Name:MERIDIAN BONE DENSITY SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RADIOLOGIC TECHNOLOGIST - OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:QUILES
Authorized Official - Suffix:
Authorized Official - Credentials:RTC
Authorized Official - Phone:253-588-7911
Mailing Address - Street 1:PO BOX 97115
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98497-0115
Mailing Address - Country:US
Mailing Address - Phone:253-588-7911
Mailing Address - Fax:253-984-6774
Practice Address - Street 1:11019 CANYON RD E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3001
Practice Address - Country:US
Practice Address - Phone:253-536-2972
Practice Address - Fax:253-826-4558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WART000031902471B0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471B0102XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistBone DensitometryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7108061Medicaid
WAAB19171Medicare ID - Type Unspecified