Provider Demographics
NPI:1124097795
Name:TRI STATE CLINIC, INC.
Entity type:Organization
Organization Name:TRI STATE CLINIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:STACY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-935-8620
Mailing Address - Street 1:1520 SLATE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:GRUNDY
Mailing Address - State:VA
Mailing Address - Zip Code:24614-6975
Mailing Address - Country:US
Mailing Address - Phone:276-935-8620
Mailing Address - Fax:276-935-4430
Practice Address - Street 1:1520 SLATE CREEK RD
Practice Address - Street 2:
Practice Address - City:GRUNDY
Practice Address - State:VA
Practice Address - Zip Code:24614-6975
Practice Address - Country:US
Practice Address - Phone:276-935-8620
Practice Address - Fax:276-935-4430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-16
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007610262Medicaid
KY35000470Medicaid
WV0034714000Medicaid
VA493829Medicare ID - Type Unspecified