Provider Demographics
NPI:1295744365
Name:GORGE BONE DENSITY TESTING LLC
Entity type:Organization
Organization Name:GORGE BONE DENSITY TESTING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLANN
Authorized Official - Middle Name:J
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-493-1467
Mailing Address - Street 1:1825 E 19TH ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3365
Mailing Address - Country:US
Mailing Address - Phone:509-493-1467
Mailing Address - Fax:509-493-3765
Practice Address - Street 1:1825 E 19TH ST
Practice Address - Street 2:SUITE 3
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3365
Practice Address - Country:US
Practice Address - Phone:509-493-1467
Practice Address - Fax:509-493-3765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORK285400OtherPACIFIC SOURCE
WA7115249OtherWASHINGTON MEDICAID
OR286691Medicaid
OR112157Medicare ID - Type Unspecified