1023302643 NPI number — TRI-STATE MEDICAL SPECIALISTS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023302643 NPI number — TRI-STATE MEDICAL SPECIALISTS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI-STATE MEDICAL SPECIALISTS LLC
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:
Provider Other Organization Name Type Code:
6
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:
1023302643
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10966
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MOHAVE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86427-0966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-788-3333
Provider Business Mailing Address Fax Number:
928-788-3555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1510 WAGON WHEEL LANE
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
FORT MOHAVE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86426-6698
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-788-3333
Provider Business Practice Location Address Fax Number:
928-788-3555
Provider Enumeration Date:
05/31/2011

Additional Information

Authorized Official

Authorized Official Last Name:
VENGER
Authorized Official First Name:
JOANN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
928-788-3333

Provider Taxonomy Codes

  • Taxonomy code: 332900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com